6.

7
Clinical Endocrinology
1. Which of the following hormones is often decreased by approximately 25% in the serum
of pregnant women who have a fetus with Down syndrome?
A. Estriol (E3)
B. Human chorionic gonadotropin (hCG)
C. Progesterone
D. Estradiol (E2)
Chemistry/Correlate laboratory data with physiological processes/Endocrine/2
2. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) causes:
A. Low serum vasopressin
B. Hypernatremia
C. Urine osmolality to be lower than plasma
D. Low serum electrolytes
Chemistry/Correlate clinical and laboratory data/Endocrine/2
3. Select the hormone which when elevated is associated with galactorrhea, pituitary
adenoma, and amenorrhea.
A. Estradiol
B. Progesterone
C. Follicle-stimulating hormone (FSH)
D. Prolactin
Chemistry/Correlate clinical and laboratory data/Endocrine/2
4. Zollinger-Ellison (Z-E) syndrome is characterized by great (e.g., 20-fold) elevation of:
A. Gastrin
B. Cholecystokinin
C. Pepsin
D. Glucagon
Chemistry/Correlate clinical and laboratory data/Gastric/2

Answers to Questions 1–4

1. A E3 is produced in the placenta and fetal liver from dehydroepiandrosterone (DHEA)
derived from the mother and from the fetal liver. E3 is the major estrogen produced
during pregnancy, and levels rise throughout gestation. Serum-free E3 is often lower
than expected for the gestational age in a pregnancy associated with Down syndrome.
The combination of low serum-free estriol, low α-fetoprotein (AFP), high hCG, and
high-inhibin A is used as a screening test to detect Down syndrome. When one of the
four markers is abnormal, amniocentesis should be performed for the diagnosis of
Down syndrome by karyotyping or fluorescence in situ hybridization (FISH). The four
 markers have a combined sensitivity (detection rate) of approximately 75%.
2. D SIADH results in excessive secretion of vasopressin (ADH) from the posterior
pituitary, causing fluid retention and low plasma osmolality, sodium, potassium, and
other electrolytes by hemodilution. It is suspected when urine osmolality is higher than
that of plasma but urine sodium concentration is normal or increased. Patients with
sodium depletion have urine osmolality higher than that of plasma, but low urine
sodium.
3. D Serum prolactin may be increased from hypothalamic dysfunction or pituitary
adenoma. When levels are greater than five times the URL, a pituitary tumor is
suspected. Prolactin is measured by immunoassay.
4. A Z-E syndrome is caused by a pancreatic or intestinal tumor secreting gastrin
(gastrinoma) and results in greatly increased gastric acid production. A serum gastrin
level 10-fold greater than the URL in a person with hyperacidity and stomach or
duodenal ulcers is diagnostic. Confirmation of gastric hyperacidity is demonstrated by
using the basal acid output (BAO) test.

5. Which statement about multiple endocrine neoplasia (MEN) is true?

A. It is associated with hyperplasia or neoplasia of at least two endocrine organs
B. Insulinoma is always present when the pituitary is involved
C. It is inherited as an autosomal recessive disorder
D. Plasma hormone levels from affected organs are elevated at least 10-fold
Chemistry/Correlate clinical and laboratory data/Endocrine/2
6. Select the main estrogen produced by the ovaries and used to evaluate ovarian function.
A. E3
B. E2
C. Epiestriol
D. Hydroxyestrone
Chemistry/Apply knowledge of fundamental biological characteristics/Estrogen/1
7. Which statement best describes the relationship between luteinizing hormone (LH) and
FSH in cases of dysmenorrhea?
A. Both are usually increased when there is pituitary adenoma
B. Increases in both hormones and a decrease in estrogen signal a pituitary cause of ovarian
failure
C. Both hormones normally peak 1 to 2 days before ovulation
D. In menopause, the LH level at the midcycle peak is higher than the level of FSH
Chemistry/Correlate clinical and laboratory data/Endocrine/2
8. When pituitary adenoma is the cause of decreased estrogen production, an increase of
which hormone is most frequently responsible?
A. Prolactin
B. FSH
C. LH
D. Thyroid-stimulating hormone (TSH)
Chemistry/Correlate clinical and laboratory data/Endocrine/2
9. Which set of results is most likely in an adult male with primary testicular failure?
 A. Increased LH, FSH, and decreased testosterone
B. Decreased LH, FSH, and testosterone
C. Decreased testosterone, androstenedione, and FSH
D. Increased androstenedione, decreased testosterone, and normal FSH
Chemistry/Correlate clinical and laboratory data/Endocrine/2

Answers to Questions 5–9

5. A MEN syndrome is inherited as an autosomal dominant disease involving excess
production of hormones from several endocrine glands. MEN I results from adenomas
(usually benign) of at least two glands, including the pituitary, adrenal cortex,
parathyroid, and pancreas. The parathyroid gland is the organ most commonly
involved, and in those patients, an elevated Cai is an early sign. The pancreas is the
next most frequently involved organ, but the hormone most commonly oversecreted is
gastrin (not insulin). MEN II is characterized by pheochromocytoma and thyroid
carcinoma. MEN II-B is a variant of MEN II showing the addition of neurofibroma.
6. B E2 is the major estrogen produced by the ovaries and gives rise to both estrone (E1) and
E3. E2 is used to evaluate both ovarian function and menstrual cycle dysfunction.
7. C In women, serum or urine LH and FSH are measured along with estrogen,
progesterone and prolactin to evaluate the cause of menstrual cycle abnormalities and
anovulation. Both hormones show a pronounced serum peak 1 to 2 days prior to
ovulation and urine peak 20 to 44 hours before ovulation. Normally, the LH peak is
sharper and greater than the FSH peak; however, in menopause, the FSH level usually
becomes higher than that of LH. In patients with primary ovarian failure, LH and FSH
are elevated because low estrogen levels stimulate release of luteinizing hormone–
releasing hormone (LHRH) from the hypothalamus. Conversely, in pituitary failure,
levels of FSH and LH are reduced, and this reduction causes a deficiency of estrogen
production by the ovaries.
8. A Prolactinoma can result in anovulation because high levels of prolactin suppress
release of LHRH (gonadotropin-releasing hormone [GRH]), causing suppression of
growth hormone (GH), FSH, and estrogen. Prolactinoma is the most commonly
occurring pituitary tumor accounting for 40% to 60%. Adenomas producing FSH have
a frequency of about 20%, whereas those pituitary tumors secreting LH and TSH are
rare.
9. A Primary testicular failure produces a picture of hypergonadotropism. LH and FSH are
increased because the pituitary gland is normal and responds to decreased free
testosterone. Androstenedione is an adrenal androgen that remains unaffected. In
testicular failure secondary to pituitary deficiency (hypogonadotropic testicular
failure), the levels of LH, FSH, and testosterone are low. In cases of mild
hypogonadism, total testosterone may be normal as a result of high sex hormone–
binding globulin (SHBG). In such cases, free testosterone, the bioavailable form, will
be low.

10. When should progesterone be measured when evaluating an adult female for
 anovulation?
A. At the onset of menses
B. During the first 7 days of the menstrual cycle
C. At the midcycle just after LH peaks
D. At the end of the menstrual cycle
Chemistry/Apply knowledge to identify sources of error/Fertility testing/2
11. A female with severe excessive pubic and facial hair growth (hirsutism) should be tested
for which of the following hormones?
A. Estrogen and progesterone
B. Chorionic gonadotropin
C. Growth hormone
D. Testosterone and dehydroepiandrosterone sulfate
Chemistry/Correlate laboratory and clinical data/Fertility testing/2
12. Which set of results is most likely in a female with hypogonadotropic ovarian failure?
A. Increased LH, FSH, and estrogen
B. Decreased LH, FSH, and estrogen
C. Decreased prolactin and estrogen
D. Increased LH and FSH, and decreased estrogen
Chemistry/Correlate laboratory and clinical data/Fertility testing/2
13. The onset of menopause is usually associated with what hormonal changes?
A. Decreased estrogen, testosterone, and androgens
B. Decreased estrogen, FSH, LH, and progesterone
C. Decreased estrogen and progesterone, and increased LH and FSH
D. Decreased estrogen and progesterone, normal LH and FSH
Chemistry/Correlate laboratory and clinical data/Fertility testing/2
14. Which of the following statements is correct in assessing GH deficiency?
A. Pituitary failure may involve one, several, or all adenohypophyseal hormones; but GH
deficiency is usually found
B. A normal random serum level of GH in a child under 6 years old rules out GH deficiency
C. Administration of arginine, insulin, or glucagon will suppress GH release
D. GH levels in the blood show little variation within a 24-hour period
Chemistry/Apply knowledge of fundamental biological characteristics/Endocrine/2

Answers to Questions 10–14

10. C Progesterone is often measured along with LH, FSH, estrogen, and prolactin to
evaluate female infertility and dysmenorrhea. Progesterone is produced by the corpus
luteum and levels are very low during the early follicular phase of the cycle.
Progesterone is released by the corpus luteum following the LH surge that occurs 1 to
2 days prior to ovulation and is an indication that ovulation occurred. Low
progesterone at midcycle indicates that ovulation did not occur. This is often the case
in polyovarian cyst syndrome.
11. D Excessive hair grown in females results from excessive androgen production and is
most commonly seen in polycystic ovarian syndrome, which produces high levels of
ovarian-derived testosterone. It will also occur as a consequence of Cushing syndrome
 and mild congenital adrenal hyperplasia (CAH). Therefore, cortisol and 17 α-
hydroxyprogesterone can help identify those causes. Rapid onset of hirsutism can
result from an ovarian or adrenal tumor. Dehydroepiandrosterone sulfate is produced
only by the adrenals and would be useful in identifying those rare cases where the
cause is an androgen-secreting adrenal tumor.
12. B Hypogonadotropic ovarian failure is the result of pituitary dysfunction. It may be
caused by low levels of both LH and FSH, or it may be caused by high levels of
prolactin as in prolactinoma because prolactin will inhibit LHRH and result in low LH
and FSH.
13. C In menopause, estrogen production decreases to the point where the menstrual cycle
and ovarian follicle maturation stop. The decreased estrogen causes the pituitary
release of LH and FSH. In menopause, the FSH level at midcycle is higher than that of
LH. The increased LH causes the ovaries to secrete testosterone and androgens.
14. A Because GH is the most abundant pituitary hormone, it may be used as a screening
test for pituitary failure in adults. Pituitary hormone deficiencies are rare and are
evaluated by measuring those hormones associated with the specific type of target
organ dysfunction. GH secretion peaks during sleep, and pulsed increases are seen
after exercise and meals. In adults, a deficiency of GH can be ruled out by
demonstrating normal or high levels on two successive tests. In children, there is
extensive overlap between normal and low GH levels, and a stimulation (provocative)
test is usually needed to establish a diagnosis of deficiency. Exercise is often used to
stimulate GH release. If GH levels are greater than 6 µg/L after vigorous exercise, then
deficiency is ruled out. In addition to exercise, certain drugs, such as arginine, insulin,
propranolol, and glucagon, can be used to stimulate GH release. Deficiency is
documented by registering a subnormal response to two stimulating agents.

15. Which statement best describes the level of GH in patients with pituitary adenoma
associated with acromegaly?
A. The fasting GH level is always elevated at least twofold
B. Some patients will require a glucose suppression test to establish a diagnosis
C. A normal fasting GH level rules out acromegaly
D. Patients produce a lower concentration of insulin-like growth factor I (IGF-1) than
expected from their GH level
Chemistry/Correlate clinical and laboratory data/Endocrine/2
16. Hyperparathyroidism is most consistently associated with:
A. Hypocalcemia
B. Hypocalciuria
C. Hypophosphatemia
D. Metabolic alkalosis
Chemistry/Correlate clinical and laboratory data/Endocrine/2
17. Which statement regarding the use of PTH is true?
A. Determination of serum PTH level is the best screening test for disorders of calcium
metabolism
B. PTH levels differentiate primary and secondary causes of hypoparathyroidism
C. PTH levels differentiate primary and secondary causes of hypocalcemia
 D. PTH levels are low in patients with pseudohypoparathyroidism
Chemistry/Correlate clinical and laboratory data/Endocrine/2
18. The best method of analysis for serum PTH involves using antibodies that react with:
A. The amino-terminal fragment of PTH
B. The carboxy-terminal end of PTH
C. The amino-terminal and either C-middle or C-terminal fragment
D. All fragments of PTH as well as intact hormone
Chemistry/Apply principles of special procedures/Hormone assays/1

Answers to Questions 15–18

15. B Approximately 90% of patients with acromegaly have an elevated fasting GH level,
but 10% do not. In addition, a single measurement is not sufficient to establish a
diagnosis of acromegaly because various metabolic and nutritional factors can cause an
elevated serum GH in the absence of pituitary disease. The glucose suppression test is
used to diagnose acromegaly. An oral dose of 100 g of glucose will suppress the serum
GH level at 1 hour (after administration) to less than 1 µg/L in normal individuals, but
not in patients with acromegaly. Patients with acromegaly also have high levels of
IGF-1, also called somatomedin C, which is overproduced by the liver in response to
excess release of GH.
16. C Hyperparathyroidism causes increased resorption of calcium and decreased renal
retention of phosphate. Increased serum calcium leads to increased urinary excretion.
The distal collecting tubule of the nephron reabsorbs less bicarbonate as well as
phosphate, resulting in acidosis.
17. C Serum Cai is the best screening test to determine if a disorder of calcium metabolism
is present, and will distinguish primary hyperparathyroidism (high Cai) and secondary
hyperparathyroidism (low Cai). PTH levels are used to distinguish primary and
secondary causes of hypocalcemia. Serum PTH is low in primary hypocalcemia (which
results from parathyroid gland disease) but is high in secondary hypocalcemia (e.g.,
renal failure). Serum PTH is also used for the early diagnosis of secondary
hypocalcemia because PTH levels rise prior to a decrease in the serum Cai. Serum PTH
is used to distinguish primary hyperparathyroidism (high PTH) and hypercalcemia of
malignancy (usually low PTH), and pseudohypoparathyroidism from primary
hypoparathyroidism. Pseudohypoparathyroidism results from a deficient response to
PTH and is associated with normal or elevated serum PTH.
18. C PTH is a polypeptide comprised of 84 amino acids. The biological activity of the
hormone resides in the N-terminal portion of the polypeptide, but the hormone is
rapidly degraded and produces N-terminal, middle, and C-terminal fragments.
Fragments lacking the N-terminal portion are inactive and N-terminal fragments do not
circulate. Immunoassays for PTH using antibodies to different portions of the
polypeptide will give different results. The assay of choice is a two-site double-
antibody sandwich method that measures intact PTH. Methods that use single
antibodies may detect inactive as well as active PTH fragments and are not as specific
for parathyroid disease.
19. Which of the following is most often elevated in hypercalcemia associated with
malignancy?
A. Parathyroid-derived PTH
B. Ectopic PTH
C. PTHRP
D. Calcitonin
Chemistry/Apply principles of special procedures/Hormone assays/1
20. Which is normally the most abundant corticosteroid hormone secreted by the adrenal
cortex?
A. Cortisol
B. Dehydroepiandrosterone
C. Aldosterone
D. Corticosterone
Chemistry/Apply knowledge of fundamental biological characteristics/Adrenal/1
21. Which of the following statements regarding adrenal cortical dysfunction is true?
A. Patients with Cushing syndrome usually have hyperkalemia
B. Cushing syndrome is associated with glucose intolerance
C. Addison disease is associated with hypernatremia
D. Addison disease is caused by elevated levels of cortisol
Chemistry/Correlate clinical and laboratory data/Adrenal/2

Answers to Questions 19–21

19. C PTHRP is a peptide produced by many tissues and normally present in blood at a very
low level. The peptide has an N-terminal sequence of eight amino acids that are the
same as those found in PTH and that will stimulate the PTH receptors of bone. Some
malignancies (e.g., squamous, renal, bladder, and ovarian cancers) secrete PTHRP,
causing hypercalcemia-associated malignancy. Because the region shared with PTH is
small and poorly immunoreactive, the peptide does not cross-react in most assays for
PTH. For this reason, and because tumors producing ectopic PTH are rare, almost all
patients who have elevated Cai and elevated PTH have primary hyperparathyroidism.
The immunoassay for PTHRP will frequently show elevated levels in patients not yet
diagnosed with malignancy but who have elevated Cai, without elevated serum PTH.
Calcitonin is a hormone produced in the medulla of the thyroid that opposes the action
of PTH. However, calcitonin levels do not greatly influence serum calcium. Assay of
calcitonin is used exclusively to diagnose medullary thyroid cancer, which produces
very high serum levels. Procalcitonin, a precursor of calcitonin, is an acute phase
reactant stimulated by bacterial endotoxin. It is measured in plasma and CSF as a
marker for bacterial infection.
20. A Cortisol is the most abundant adrenal hormone, and abnormal levels have pronounced
effects on carbohydrate and lipid metabolism. Cortisol is a 21-carbon steroid with a
dihydroxyacetone group at C17 and hydroxyl group at C11 which account for its
glucocorticoid potency. Plasma and urinary cortisol measurements are used to
diagnose most types of adrenocortical dysfunction. DHEA, an adrenal androgen, is the
next most abundant adrenal hormone. Aldosterone is the principal mineral corticoid
 made by the adrenals, and corticosterone is the immediate precursor to aldosterone.
Both regulate salt balance.
21. B Patients with Cushing syndrome have elevated levels of cortisol and other adrenal
corticosteroids. This causes the characteristic cushingoid appearance that includes
obesity, acne, and humpback posture. Osteoporosis, hypertension, hypernatremia,
hypokalemia, and glycosuria are characteristic features. Addison disease results from
adrenal hypoplasia and produces the opposite symptoms, including hypotension,
hyponatremia, hyperkalemia, and hypoglycemia.

22. Which of the following statements about cortisol in Cushing syndrome is true?
A. Twenty-four–hour urinary free cortisol is a more sensitive test than plasma total cortisol
B. Patients with Cushing disease show pronounced diurnal variation in serum cortisol
C. Free cortisol is increased by a high-serum cortisol-binding protein concentration
D. An elevated serum total cortisol level is diagnostic of Cushing syndrome
Chemistry/Apply knowledge to identify sources of error/Cortisol/2
23. Which of the following conditions is characterized by primary hyperaldosteronism
caused by adrenal adenoma, carcinoma, or hyperplasia?
A. Cushing syndrome
B. Addison disease
C. Conn syndrome
D. Pheochromocytoma
Chemistry/Correlate clinical and laboratory data/Endocrine/2
24. Which of the following is the most common cause of Cushing syndrome?
A. Pituitary adenoma
B. Adrenal hyperplasia
C. Overuse of corticosteroids
D. Ectopic adrenocorticotropic hormone (ACTH) production by tumors
Chemistry/Correlate clinical and laboratory data/Adrenal/2
25. Which of the following is the mechanism causing Cushing disease?
A. Excess secretion of pituitary ACTH
B. Adrenal adenoma
C. Treatment with corticosteroids
D. Ectopic ACTH production by tumors
Chemistry/Apply knowledge of fundamental biological characteristics/Adrenal/2
26. In which situation is the plasma or 24-hour urinary cortisol not consistent with the
clinical picture?
A. In pregnant patients
B. In patients with a positive result on the overnight dexamethasone suppression test
C. In congenital adrenal hyperplasia
D. In Cushing syndrome caused by ectopic ACTH-producing tumors
Chemistry/Apply knowledge to recognize inconsistent results/Adrenal/2

Answers to Questions 22–26

22. A Serum cortisol can be increased by such factors as stress, medications, and cortisol-
 binding protein, and the cortisol level of normal individuals will overlap those seen in
Cushing syndrome because of pulse variation. When cortisol levels become elevated,
cortisol-binding protein becomes saturated, and free (unbound) cortisol is filtered by
the glomeruli. Most of it is reabsorbed, but a significant amount reaches the urine as
free cortisol. Twenty-four–hour urinary free cortisol avoids the diurnal variation that
may affect plasma free cortisol levels and is a more sensitive test than serum total or
free cortisol.
23. C Conn syndrome is characterized by hypertension, hypokalemia, and hypernatremia,
with increased plasma and urine aldosterone and decreased renin. Cushing syndrome
results from excessive production of cortisol, and Addison disease results from
deficient production of adrenal corticosteroids. Pheochromocytoma is a tumor of
chromaffin cells (usually adrenal) that produces catecholamines.
24. C The most common cause of Cushing syndrome is the administration of medications
with cortisol or glucocorticoid activity. Excluding iatrogenic causes, in approximately
60% to 70% of cases, Cushing syndrome results from hypothalamic–pituitary
misregulation and is called Cushing disease. Adrenal adenoma or carcinoma (non-
ACTH–mediated Cushing syndrome) comprise about 20% of cases, and ectopic ACTH
production accounts for 10% to 20%.
25. A Cushing disease refers to adrenal hyperplasia resulting from misregulation of the
hypothalamic–pituitary axis. It is usually caused by small pituitary adenomas. Cushing
syndrome may be caused by Cushing disease, adrenal adenoma or carcinoma, ectopic
ACTH-producing tumors, or excessive corticosteroid administration. The cause of
Cushing syndrome can be differentiated by using ACTH and dexamethasone
suppression tests.
26. C CAH (adrenogenital syndrome) results from deficiency of an enzyme required for
synthesis of cortisol. Approximately 90% of cases are caused by a deficiency of 21-
hydroxylase blocking conversion of 17 α-hydroxyprogesterone to 11-deoxycortisol.
Most other cases are caused by 11-hydroxylase deficiency, which blocks conversion of
11-deoxycortisol to cortisol. Precursors of cortisol, usually either 17 α-
hydroxyprogesterone or 11-deoxycortisol are increased. This results in low serum
cortisol levels but high levels of these intermediates. The two most common features of
CAH are salt wasting caused by increased mineral corticoid activity and virilization
caused by increased androgens.

27. Which test is used to distinguish Cushing disease (pituitary Cushing) from Cushing
syndrome caused by adrenal tumors?
A. Low-dose overnight dexamethasone suppression
B. Inferior petrosal sinus sampling
C. Serum ACTH
D. 24-hour urine free cortisol
Chemistry/Select course of action/Adrenal/2
28. Which is the most widely used screening test for Cushing syndrome?
A. Overnight low-dose dexamethasone suppression test
B. Corticotropin-releasing hormone (CRH) stimulation test
C. Inferior petrosal sinus sampling
 D. Metyrapone stimulation test
Chemistry/Select course of action/Adrenal/2
29. Which test is the most specific for establishing a diagnosis of Cushing disease (pituitary
Cushing)?
A. Low-dose dexamethasone suppression
B. High-dose dexamethasone suppression
C. 24-hour urine free cortisol
D. Petrosal sinus sampling after CRH stimulation
Chemistry/Correlate clinical and laboratory data/Adrenal/2

Answers to Questions 27–29

27. C Serum ACTH assays are very helpful in distinguishing the cause of Cushing
syndrome. Patients with adrenal tumors have values approaching zero. Patients with
ectopic ACTH tumors have values greater than 200 pg/dL. Fifty percent of patients
with Cushing disease have high 8 a.m. ACTH levels (100–200 pg/dL). The high-dose
dexamethasone suppression test is also used. Patients with Cushing disease show more
than 50% suppression of cortisol release after receiving an 8-mg dose of
dexamethasone, but patients with adrenal tumors or ACTH-producing tumors do not.
Inferior petrosal sinus sampling (the petrosal sinuses drain the pituitary) is used to
determine if a high ACTH is from the pituitary glands or from an ectopic source.
28. A Dexamethasone is a synthetic corticosteroid that exhibits 30-fold greater negative
feedback on the hypothalamus compared with cortisol. When an oral dose of 1 mg of
the drug is given to a patient at 11 p.m., the 8 a.m. serum total cortisol level should be
below 5.0 µg/dL. Patients with Cushing syndrome almost always exceed this cutoff.
Therefore, a normal response to dexamethasone excludes Cushing syndrome with a
sensitivity of about 98%. CRH stimulation and petrosal sinus sampling are
confirmatory tests for Cushing disease and are used when the high-dose
dexamethasone suppression test is inconclusive. The metyrapone stimulation test
measures the patient’s ACTH reserve. Metyrapone blocks cortisol formation by
inhibiting 11β-hydroxylase. This causes an increase in ACTH output in normal
individuals. A subnormal ACTH response is seen in persons with Addison disease
caused by pituitary failure.
29. D Although dexamethasone suppression tests have a high sensitivity, some individuals
without Cushing syndrome have indeterminate results (e.g., values between 5 and 10
µg/dL) or abnormal results caused by medications or other conditions. When CRH (or
desmopressin) is given intravenously, patients with Cushing disease have an
exaggerated ACTH response. Samples are drawn from the sinuses draining the
pituitary gland and from the peripheral blood. In patients with pituitary tumors, the
ACTH level will be several times higher in the sinus samples than in the peripheral
blood samples. Inferior petrosal sinus sampling can determine if the microadenomas
are bilateral and, if not, on which side they are on.

30. Which of the following statements about the diagnosis of Addison disease is true?
A. Patients with primary Addison disease show a normal response to ACTH stimulation
 B. Primary and secondary Addison disease can often be differentiated by plasma ACTH
C. 24-hour urinary free cortisol is normal in Addison disease
D. Pituitary ACTH reserves are normal in secondary Addison disease
Chemistry/Correlate clinical and laboratory data/Adrenal/2
31. Which of the following statements regarding the catecholamines is true?
A. They are derived from tryptophan
B. They are produced by the zona glomerulosa of the adrenal cortex
C. Plasma levels show both diurnal and pulsed variation
D. They are excreted in urine primarily as free catecholamines
Chemistry/Apply knowledge of fundamental biological characteristics/Catecholamines/2
32. Which assay is considered the best single screening test for pheochromocytoma?
A. Total urinary catecholamines
B. VMA
C. HVA
D. Plasma free metanephrines
Chemistry/Correlate clinical and laboratory data/Catecholamines/2
33. Which metabolite is most often increased in carcinoid tumors of the intestine?
A. 5-Hydroxyindolacetic acid (5-HIAA)
B. 3-Methoxy-4-hydroxyphenylglycol (MHPG)
C. 3-Methoxydopamine
D. Homovanillic acid
Chemistry/Correlate clinical and laboratory data/Endocrine/1

Answers to Questions 30–33

30. B ACTH (Cortrosyn) stimulation is used as a screening test for Addison disease. A 250-
µg dose of Cortrosyn is given intravenously. Normal individuals show a two to five
times increase in serum cortisol. A subnormal response occurs in both primary and
secondary Addison disease. Plasma ACTH is high in primary but is low in secondary
Addison disease. Patients with secondary Addison disease (pituitary failure) do not
respond to metyrapone because their ACTH reserve is diminished.
31. C Catecholamines—epinephrine, norepinephrine, and dopamine—are produced from
the amino acid tyrosine by the chromaffin cells of the adrenal medulla. Plasma and
urinary catecholamines are measured to diagnose pheochromocytoma. Symptoms
include hypertension, headache, sweating, and other endocrine involvement. Plasma
catecholamines are oxidized rapidly to metanephrines and VMA; only about 2% is
excreted as free catecholamines. The zona glomerulosa is the outermost portion of the
adrenal cortex, where aldosterone is mainly produced. Cortisol is made in the zona
fasciculata.
32. D Catecholamines are metabolized to metanephrines and VMA. Urinary catecholamines
are increased by exercise and dietary ingestion. Measurement of plasma free
metanephrine is about 96% sensitive for pheochromocytoma, and is the best single test
followed by 24-hour urinary metanephrines, which is slightly less sensitive but more
specific. Specificity and sensitivity for detecting pheochromocytoma approach 100%
when both VMA and metanephrines are measured.
 33. A 5-HIAA is a product of serotonin catabolism. Excess levels are found in the urine of
patients with carcinoid tumors composed of argentaffin cells. Carcinoid tumors are
usually found in the intestine or lung, and produce serotonin and 5-hydroxytryptophan,
a serotonin precursor. Serotonin is deaminated by monamine oxidase, forming 5-
HIAA, and the 5-HIAA is excreted in urine. Some carcinoid tumors produce mainly 5-
hydroxytryptophan because they lack an enzyme needed to convert it to serotonin. 5-
hydroxytryptophan is converted by the kidneys to serotonin resulting in high urinary
serotonin. Both 5-HIAA and serotonin are usually measured by using HPLC with
electrochemical detection.

34. Which statement regarding the measurement of urinary catecholamines is true?

A. An increased excretion of total urinary catecholamines is specific for pheochromocytoma
B. Twenty-four–hour urinary catecholamine assay avoids pulse variations associated with
measurement of plasma catecholamines
C. Total urinary catecholamine measurement provides greater specificity than measurement
of urinary free fractionated catecholamines
D. Total urinary catecholamines are not affected by exercise
Chemistry/Apply knowledge to identify sources of error/Catecholamines/2
35. Which method is most often used to measure fractionated catecholamines (epinephrine,
norepinephrine, and dopamine)?
A. Measurement of fluorescence following oxidation by potassium ferricyanide
B. Measurement by HPLC with electrochemical detection
C. Measure of radioactivity after conversion by catechol-O-methyltransferase (COMT) to
tritiated metanephrines
D. Measurement by immunoassay
Chemistry/Apply principles of special procedures/Catecholamines/2
36. Which statement about sample collection for catecholamines and metabolites is true?
A. Blood for catecholamines is collected in the usual manner following a 12-hour fast
B. Twenty-four–hour urine for VMA, catecholamines, or metanephrines is collected in 1 mL
of boric acid
C. Twenty-four–hour urine creatinine should be measured with VMA, HVA, or
metanephrines
D. There is no need to discontinue medications if a 24-hour urine collection is used
Chemistry/Apply principles of special procedures/Specimen collection and handling/2

Answers to Questions 34–36

34. B Measurement of total urinary catecholamines is not a specific test for
pheochromocytoma. Urine levels may be increased by exercise and in muscular
diseases. Catecholamines in urine may also be derived from dietary sources rather than
endogenous production. Most catecholamines are excreted as the glucuronide, and the
urinary free catecholamines increase only when there is increased secretion.
Measurement of free fractionated hormones in urine is somewhat lower in both clinical
sensitivity and specificity than measurement of metanephrines. Twenty-four–hour
urine is the sample of choice because plasma levels are subject to pulse variation and
affected by the patient’s psychological and metabolic condition at the time of
 sampling.
35. B HPLC–ECD separates catecholamines by reverse-phase chromatography, then detects
them by oxidizing the aromatic ring at +0.8 V to a quinone ring. Current is
proportional concentration, and the method fractionates catecholamines into
epinephrine, norepinephrine, and dopamine. Fluorescent methods employing
ferricyanide (trihydroxyindole method) or ethylenediamine (EDA method) show
interference from several drugs and are obsolete. ESI-MS/MS is an alternative to
HPLC-EDC for measurement of fractionated catecholamines and metanephrines.
Immunoassays require derivatization of catecholamines, have extensive incubation
times and do not fractionate catecholamines. Measurement of fractionated
catecholamines is preferred because it can detect an abnormal ratio of norepinephrine
to epinephrine, which is seen in pheochromocytoma, and increased dopamine, which is
found in extra-adrenal tumors.
36. C Stress, exercise, and an upright position induce catecholamine elevation, and
therefore, patients must be resting in the supine position for at least 30 minutes prior to
blood collection. The preferred method of collection is catheterization so that the
anxiety of venipuncture is not a factor. A 4-hour fast is also recommended. Many
drugs contain epinephrine, which may falsely elevate catecholamine levels. In
addition, many drugs inhibit monoamine oxidase, which is needed to convert
metanephrines to VMA. Therefore, medications should be temporarily discontinued
prior to testing, whenever possible. Twenty-four–hour urine samples for
catecholamines are usually preserved with 10 mL of 6N HCl because some
degradation occurs during storage when pH is greater than 3. Renal clearance affects
excretion of catecholamine metabolites; it is preferable to report VMA, HVA, and
metanephrines, in micrograms per milligram of creatinine. Urine creatinine excretion
should be at least 0.8 g/day, to validate the completeness of the 24-hour urine sample.

37. Which of the following statements applies to measurement of both VMA and
metanephrines in urine?
A. Both can be oxidized to vanillin and measured at 360 nm without interference from
dietary compounds
B. Both can be measured immunochemically after hydrolysis and derivatization
C. Both require acid hydrolysis prior to measurement
D. Both can be measured by specific HPLC and MS assays
Chemistry/Apply principles of special procedures/Catecholamines/2
38. Urinary HVA is most often assayed to detect:
A. Pheochromocytoma
B. Neuroblastoma
C. Adrenal medullary carcinoma
D. Psychiatric disorders, such as manic depression
Chemistry/Correlate laboratory and clinical data/Catecholamines/1
39. Thyroid hormones are derived from the amino acid:
A. Phenylalanine
B. Methionine
C. Tyrosine
 D. Histidine
Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/1
40. Which statement regarding thyroid hormones is true?
A. Circulating levels of T3 and T4 are about equal
B. T3 is about 10-fold more active than T4
C. The rate of formation of monoiodotyrosine and diiodotyrosine is about equal
D. Most of the T3 present in plasma is from its direct release from thyroid storage sites
Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/2
41. Which of the following statements regarding thyroid hormones is true?
A. Both protein-bound and free triiodothyronine (T3) and thyroxine (T4) are physiologically
active
B. Total T3 and T4 are influenced by the level of thyroxine-binding globulin
C. Variation in thyroxine-binding protein levels affects both free T3 and T4
D. An elevated serum total T4 and T3 is diagnostic of hyperthyroidism
Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/2
42. Which of the following conditions will increase total T4 by increasing thyroxine-binding
globulin (TBG)?
A. Acute illness
B. Anabolic steroid use
C. Nephrotic syndrome
D. Pregnancy or estrogens
Chemistry/Correlate clinical and laboratory data/Thyroid/2

Answers to Questions 37–42

37. D VMA and metanephrines can both be measured as vanillin after oxidation with
periodate. However, these methods are affected by dietary sources of vanillin; coffee,
chocolate, bananas, and vanilla must be excluded from the diet. Metanephrines, VMA,
and HVA are most often measured by using HPLC-EDC.
38. B HVA is the major metabolite of dopa, and urinary HVA is elevated in greater than
75% of patients with neuroblastoma. Neuroblastomas also usually produce VMA from
norepinephrine. Thus, HVA and VMA are assayed together, and this increases the
sensitivity of detection to around 90%.
39. C Thyroid hormones are derived from the enzymatic modification of tyrosine residues
on thyroglobulin. Tyrosine is halogenated enzymatically with iodine, forming
monoiodotyrosine (MIT) and diiodotyrosine (DIT). Enzymatic coupling of these
residues form T3 (3,5,3’-triiodothyronine) and T4 (3,5,3’,5’-tetraiodothyronine). These
are hydrolyzed from thyroglobulin, forming active hormones.
40. B The rate of DIT synthesis is twice that of MIT and the rate of coupling favors
formation of T4. Levels of T4 are about 50 times those of T3, but T3 is approximately
10 times more active physiologically. Eighty percent of circulating T3 is derived from
enzymatic conversion of T4 by T4 5’-deiodinase.
 41. B Total serum T4 and T3 are dependent on both thyroid function and the amount of T4-
binding proteins, such as TBG. Total T4 or T3 may be abnormal in a patient with
normal thyroid function, if the TBG level is abnormal. For this reason, free T3 and T4
are more specific indicators of thyroid function than are measurements of total
hormone. Only free hormone is physiologically active.
42. D Pregnancy and estrogens are the most common causes of increased TBG. Other
causes include hepatitis, morphine, and clofibrate therapy. Acute illness, anabolic
steroids, and nephrotic syndrome decrease the level of TBG. Normal pregnancy causes
an elevated serum total T4. Suitable assays that estimate free T4 and T3 are available
and should be used instead of total hormone assays.

43. Select the most appropriate single screening test for thyroid disease.
A. Free T4 index
B. Free T3
C. Free T4
D. TSH assay
Chemistry/Correlate clinical and laboratory data/Thyroid/2
44. The serum TSH level is almost absent in:
A. Primary hyperthyroidism
B. Primary hypothyroidism
C. Secondary hyperthyroidism
D. Euthyroid sick syndrome
Chemistry/Correlate clinical and laboratory data/Thyroid/1
45. Which assay is used to confirm difficult cases of hypothyroidism?
A. Free T3 assay
B. Free T4 index
C. Thyrotropin-releasing hormone (TRH) stimulation test
D. TBG assay
Chemistry/Correlate clinical and laboratory data/Thyroid/2
46. Which of the following statements is true regarding reverse T3 (rT3)?
A. Formed in blood by degradation of T4
B. Physiologically active, but less than T3
C. Decreased in euthyroid sick syndrome
D. Interferes with the measurement of serum T3
Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/2
47. A patient has an elevated serum-free T3 and free T4 and undetectable TSH. What is the
most likely cause of these results?
A. Primary hyperthyroidism
B. Secondary hyperthyroidism
C. Euthyroid with increased TBG
D. Euthyroid sick syndrome
Chemistry/Correlate clinical and laboratory data/Thyroid/3
48. A serum thyroid panel reveals an increase in total T4, normal TSH, and normal free T4.
What is the most likely cause of these results?
A. Primary hyperthyroidism
B. Secondary hyperthyroidism
C. Euthyroid with increased TBG
D. Subclinical hypothyroidism
Chemistry/Correlate clinical and laboratory data/Thyroid/3

Answers to Questions 43–48

43. D TSH is produced by the anterior pituitary in response to low levels of free T4 or T3. A
normal TSH rules out thyroid disease. TSH is low in primary hyperthyroidism and
high in primary hypothyroidism.
44. A Low TSH and a high T3 occur in primary hyperthyroidism but may also occur in
systemic nonthyroid illnesses where T4 has been converted to T3. A twofold increase
in free hormone can produce a 100-fold decrease in TSH. In primary hyperthyroidism,
TSH will usually be within a range of 0 to 0.02 mU/mL, whereas in nonthyroid
illnesses it will be 0.03 mU/mL or greater. High TSH and low T4 levels occur in
primary hypothyroidism but may also be seen in an acutely ill patient without thyroid
disease (euthyroid sick syndrome). Secondary hyperthyroidism is caused by pituitary
hyperfunction that increases TSH.
45. C The TRH stimulation test is used to confirm borderline cases of abnormal thyroid
function. In normal individuals, intravenous (IV) injection of 500 µg of TRH causes a
peak TSH response within 30 minutes. In patients with primary hypothyroidism, there
is an exaggerated response (greater than 30 mU/L). Patients with hyperthyroidism do
not show the expected rise in TSH after TRH stimulation.
46. A Reverse T3 (3,3’,5’-triiodothyronine) is formed from the deiodination of T4 in blood.
It is an inactive isomer of T3. Reverse T3 is increased in acute and chronic illnesses and
is used to identify patients with euthyroid sick syndrome.
47. A An undetectable TSH with increased T3 is caused by primary hyperthyroidism
(suppression via high free thyroid hormone). In secondary hyperthyroidism, TSH will
be elevated in addition to, at least, T3. Patients with an increased TBG level will have
an increase in total T3 and T4, but not free T3,T4 or TSH. Patients with euthyroid sick
syndrome usually have a small decrease in free T4 and a normal or slightly elevated
TSH as a result of peripheral conversion of T4 to rT3.
48. C Individuals with a normal TSH level are euthyroid, and most commonly, an increase
in total T4 is caused by an increase in TBG. An increase in TBG causes an increase in
total T4 but not free T4. Subclinical hypothyroidism is usually associated with a high
TSH, but normal free T3 and free T4. When TSH is indeterminate, the diagnosis is
made by demonstrating an exaggerated response to the TRH stimulation test.

49. Which statement about TSH and T4 in early pregnancy is correct?

 A. TSH and thyroid hormones fall
B. TSH falls and thyroid hormones rise
C. TSH and thyroid hormones both rise
D. TSH rises and thyroid hormones fall
Chemistry/Correlate clinical and laboratory data/Thyroid/3
50. In which case might a very low plasma TSH result not correlate with thyroid status?
A. Euthyroid sick syndrome
B. Congenital hypothyroidism
C. When TBG is elevated
D. After high-dose corticosteroid treatment
Chemistry/Correlate clinical and laboratory data/Thyroid/3

Answers to Questions 49–50

49. B Estrogens released in pregnancy cause an increase in TBG, which causes an increase
in total T4 and T3. In early pregnancy, hCG produced by the placenta stimulates the
thyroid, causing an increase in free thyroid hormones. This suppresses TSH
production. In the second trimester, as hCG diminishes, free T4 levels fall and may be
lower than 0.8 ng/dL, the lower limit of the adult reference range resulting from
expansion of the blood volume. Therefore, both TSH and free T4 should be evaluated
during pregnancy by using trimester-specific reference ranges. In early pregnancy, a
TSH above the first- trimester reference range should be followed up with free T4 and
thyroid peroxidase antibody levels to assess the need for thyroid treatment.
50. D In persons with severe chronic diseases or in those who have hCG-secreting tumors,
TSH production may be suppressed. Some drugs, especially high doses of
corticosteroids, will suppress TSH production. Low TSH levels not matching thyroid
status can also be seen in patients who have recently been treated for hyperthyroidism
because there is a delay in the pituitary response. High-sensitivity TSH assays that can
measure as little as 0.01 mIU/L and free T4 and T3 can help differentiate these
conditions from clinical hyperthyroidism. If the TSH is below 0.03 mIU/L and the free
hormone levels are increased, this points to hyperthyroidism. Laboratory values in
euthyroid sick syndrome may mimic mild hypothyroidism. In euthyroid sick
syndrome, thyroid function will be normal, but TSH may be slightly increased because
of lower levels of free T3 or T4. In euthyroid sick syndrome, the rT3 will be increased.
 6.8
Toxicology and Therapeutic Drug Monitoring
1. In which of the following cases is qualitative analysis of the drug usually adequate?
A. To determine whether the dose of a drug with a low therapeutic index is likely to be toxic
B. To determine whether a patient is complying with the physician’s instructions
C. To adjust dose if individual differences or disease alter expected response
D. To determine whether the patient has been taking amphetamines
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/1
2. The term pharmacokinetics refers to the:
A. Relationship between drug dose and the drug blood level
B. Concentration of drug at its sites of action
C. Relationship between blood concentration and therapeutic response
D. The relationship between blood and tissue drug levels
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/1
3. The term pharmacodynamics is an expression of the relationship between:
A. Dose and physiological effect
B. Drug concentration at target sites and physiological effect
C. Time and serum drug concentration
D. Blood and tissue drug levels
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/1
4. The study of pharmacogenomics involves which type of testing?
A. Familial studies to determine the inheritance of drug resistance
B. Testing drugs with cell cultures to determine the minimum toxic dosage
C. Testing for single nucleotide polymorphisms known to affect drug metabolism
D. Comparison of dose–response curves between family members
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/1

Answers to Questions 1–4

1. D The purpose of therapeutic drug monitoring is to achieve a therapeutic blood drug level
rapidly and minimize the risk of drug toxicity caused by overdose. Therapeutic drug
monitoring is a quantitative procedure performed for drugs with a narrow therapeutic
index (ratio of the concentration producing the desired effect to the concentration
producing toxicity). Drug groups that require monitoring because of high risk of
toxicity include aminoglycoside antibiotics, anticonvulsants, antiarrhythmics,
antiasthmatics, immunosuppressive agents used for transplant rejection, and
 psychoactive drugs. When testing for abuse substances, the goal is usually to determine
whether the drug is present or absent. The most common approach is to compare the
result with a cutoff value determined by measuring a standard containing the lowest
level of drug that is considered significant.
2. A Pharmacokinetics is the mathematical expression of the relationship between drug dose
and drug blood level. When the appropriate formula is applied to quantitative
measurements of drug dose, absorption, distribution, and elimination, the dose needed
to achieve a therapeutic blood concentration can be accurately determined.
3. B Pharmacodynamics is the relationship between the drug concentration at the receptor
site (tissue concentration) and the response of the tissue to that drug. For example, the
relationship between lidocaine concentration in the heart muscle and the duration of
the action potential of Purkinje fibers.
4. C Pharmacogenomics refers to the study of genes that affect the concentration of a drug
in an individual. One method is to test for single nucleotide polymorphisms (SNPs) by
using DNA microarrays in genes, such as those that code for the cytochrome P450
enzymes involved in the metabolism of many drugs. Genetic variations of one such
enzyme may account for individual pharmacokinetic differences and can be used to
predict the efficacy of the drug.

5. Select the five pharmacologic parameters that determine serum drug concentration.
A. Absorption, anabolism, perfusion, bioactivation, excretion
B. Liberation, equilibration, biotransformation, reabsorption, elimination
C. Liberation, absorption, distribution, metabolism, excretion
D. Ingestion, conjugation, integration, metabolism, elimination
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/1
6. Which route of administration is associated with 100% bioavailability?
A. Sublingual
B. Intramuscular
C. Oral
D. Intravenous
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
7. The phrase “first-pass hepatic metabolism” means that:
A. One hundred percent of a drug is excreted by the liver
B. All drug is inactivated by hepatic enzymes after one pass through the liver
C. Some drug is removed from the portal circulation, reducing bioavailability
D. The drug must be metabolized in the liver to an active form
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
8. Which formula can be used to estimate dosage needed to give a desired steady-state
blood level?
A. Dose per hour = clearance (milligrams per hour) × average concentration at steady state ÷
f
B. Dose per day = fraction absorbed – fraction excreted
 C. Dose = fraction absorbed × (1/protein-bound fraction)
D. Dose per day = half-life × log Vd (volume distribution)
Chemistry/Calculate/Therapeutic drug monitoring/2

Answers to Questions 5–8

5. C Liberation is the release of the drug, and absorption is the transport of drug from the
site of administration to blood. The percent of drug absorption and the rate of
absorption determine the bioavailable fraction, f. This is the fraction of the dose that
reaches the bloodstream. Distribution refers to the delivery of the drug to tissues. It
involves dilution and equilibration of the drug in various fluid compartments, including
blood, and is influenced by binding to proteins and blood cells. Metabolism is the
process of chemical modification of the drug by cells. This results in production of
metabolites with altered activity and solubility. Excretion is the process by which the
drug and its metabolites are removed from the body.
6. D When a drug is administered intravenously, all of the drug enters the bloodstream, and
therefore, the bioavailable fraction is 1.0. All other routes of administration require
absorption through cells, and this process reduces the bioavailable fraction. The
bioavailable fraction for a drug given orally can be calculated by dividing the peak
blood concentration after oral administration by the peak drug concentration after IV
administration. A value of 0.7 or greater is desired for drugs given orally.
7. C Drugs given orally usually enter the blood via the portal circulation and are transported
directly to the liver. Some drugs are excreted by the liver, and a fraction will be lost by
hepatic excretion before the drug reaches the general circulation. An example is
propranolol, a β-blocker that reduces heart rate and hypertension. The bioavailable
fraction is 0.2 to 0.4 when given orally because much of the drug is removed by first-
pass hepatic metabolism.
8. A After a patient receives a loading dose to rapidly bring the drug level up to the desired
therapeutic range, a maintenance dose must be given at consistent intervals to maintain
the blood drug level at the desired concentration. The dose per hour is determined by
multiplying the clearance per hour by the desired average steady-state concentration,
then dividing by f (bioavailable fraction).

9. Which statement is true regarding the volume distribution (Vd) of a drug?

A. Vd is equal to the peak blood concentration divided by the dose given
B. Vd is the theoretical volume in liters into which the drug distributes
C. The higher the Vd, the lower is the dose needed to reach the desired blood level of drug
D. The Vd is the principal determinant of the dosing interval
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
10. For drugs with first-order elimination, which statement about drug clearance is true?
A. Clearance = elimination rate ÷ serum level
B. It is most often performed by the liver
C. It is directly related to half-life
 D. Clearance rate is independent of dose
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
11. Which statement about steady-state drug levels is true?
A. The absorbed drug must be greater than the amount excreted
B. Steady state can be measured after two elimination half-lives
C. Constant IV infusion will give the same minima and maxima as an oral dose
D. Oral dosing intervals give peaks and troughs in the dose–response curve
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
12. If too small a peak–trough difference is seen for a drug given orally, then:
A. The dose should be decreased
B. Time between doses should be decreased
C. Dose interval should be increased
D. Dose per day and time between doses should be decreased
Chemistry/Select course of action/Therapeutic drug monitoring/3
13. If the peak level is appropriate but the trough level too low at steady state, then the dose
interval should:
A. Be lengthened without changing the dose per day
B. Be lengthened and dose rate decreased
C. Not be changed, but dose per day increased
D. Be shortened, but dose per day not changed
Chemistry/Select source of action/Therapeutic drug monitoring/3

Answers to Questions 9–13

9. A B The Vd of a drug represents the dilution of the drug after it has been distributed in
the body. Vd is used to estimate the loading dose needed to achieve the desired peak
drug blood level. The peak blood level equals the dose multiplied by f ÷ Vd. Vd can be
calculated by dividing the dose, Xo, by the initial plasma drug concentration, Co, (Vd =
Xo/Co) or by dividing the clearance rate by K, the elimination rate constant (K = 0.693
divided by drug half-life). The greater the Vd, the higher is the dose that will be needed
to achieve the desired blood concentration of the drug. Vd is the principal determinant
of the dose, and the clearance rate is the principal determinant of the dosing interval.
10. A First-order elimination represents a linear relationship between the amount of drug
eliminated per hour and the blood level of the drug. For drugs following linear kinetics,
clearance equals the elimination rate divided by the drug concentration in blood. When
clearance (in milligrams per hour) and f are known, the dose per hour needed to give a
desired average drug level at steady state can be calculated. Clearance is inversely
related to the drug’s half-life and is accomplished mainly by the kidneys.
11. D When drugs are infused through a steady IV drip, both the distribution and
elimination rates are constant. This eliminates the peaks and troughs seen in the dose–
response curve. Peak and trough levels are characteristics of intermittent dosing
 regimens. The steady state is reached when drug in the next dose is sufficient only to
replace the drug eliminated since the last dose. Steady state can be measured after five
drug half-lives because blood levels will have reached 97% of steady state.
12. C Increasing the dosing interval will reduce the trough concentration of the drug, and
increasing the dose will increase the peak concentration of the drug, resulting in a
greater peak–trough difference. Initially, the peak–trough ratio is usually adjusted to 2
with the dose interval set to equal the drug half-life. Under these conditions, both peak
and trough levels often fall within the therapeutic range.
13. D Increasing the dose rate may result in peak drug levels in the toxic range. Decreasing
the dosing interval will raise the trough level so that it is maintained in the therapeutic
range. The trough level is affected by the drug clearance rate. If clearance increases,
then trough level decreases.

14. If the steady-state drug level is too high, the best course of action is to:
A. Decrease the dose
B. Decrease the dose interval
C. Decrease the dose and decrease the dose interval
D. Change the route of administration
Chemistry/Select course of action/Therapeutic drug monitoring/3
15. When should blood samples for trough drug levels be collected?
A. 30 minutes after peak levels
B. 45 minutes before the next dose
C. 1 to 2 hours after the last dose
D. Immediately before the next dose is given
Chemistry/Apply knowledge to recognize sources of error/Sample collection and handling/2
16. Blood sample collection time for peak drug levels:
A. Varies with the drug, depending on its rate of absorption
B. Is independent of drug formulation
C. Is independent of the route of administration
D. Is 30 minutes after a bolus IV injection is completed
Chemistry/Apply knowledge to recognize sources of error/Sample collection and handling/2
17. Which could account for drug toxicity following a normally prescribed dose?
A. Decreased renal clearance caused by kidney disease
B. Discontinuance or administration of another drug
C. Altered serum protein binding caused by disease
D. All of these options
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
18. Select the elimination model that best describes most oral drugs given at therapeutic
doses.
A. One compartment, linear first-order elimination
B. Michaelis-Menton or nonlinear elimination
C. Two compartment with a biphasic elimination curve
D. Logarithmic elimination
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
 monitoring/2
19. Drugs rapidly infused intravenously usually follow which elimination model?
A. One compartment, first order
B. One compartment, logarithmic
C. Biphasic or two compartment with serum level rapidly falling in the first phase
D. Michaelis-Menton or concentration-dependent elimination
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2

Answers to Questions 14–19

14. A Decreasing both dose and dosing interval will have offsetting effects on peak and
trough blood levels. The appropriate dose can be calculated if the clearance or Vd and f
are known. For example, the initial IV dose is calculated by multiplying the desired
peak blood concentration of the drug by the Vd.
15. D The trough concentration of a drug is the lowest concentration obtained in the dosing
interval. This occurs immediately before the absorption of the next dose given. Trough
levels are usually collected just before the next dose is given.
16. A The peak concentration of a drug is the highest concentration obtained in the dosing
interval. For oral drugs, the time of peak concentration is dependent on their rates of
absorption and elimination and is determined by serial blood measurements. Peak
levels for oral drugs are usually drawn 1 to 2 hours after administration of the dose.
For drugs given intravenously, peak levels are measured immediately after the infusion
is completed.
17. D Therapeutic drug monitoring is necessary for drugs that have a narrow therapeutic
index. Individual differences alter pharmacokinetics, causing lack of correlation
between dose and blood level of the drug. These include age, diet, ingestion with or
without food, genetic factors, exercise, smoking, pregnancy, metabolism of other
drugs, protein binding, and disease states.
18. A Most drugs given orally distribute uniformly through the tissues reaching rapid
equilibrium, so both blood and tissues can be viewed as a single compartment.
Elimination according to Michaelis-Menton kinetics is nonlinear because at high
concentrations, the hepatic enzyme system becomes saturated, reducing the elimination
efficiency. Therefore, at high serum concentrations, most first-order drugs transition to
nonlinear elimination rates.
19. C Drugs rapidly infused intravenously follow a two-compartment model of elimination.
The central compartment is the blood and tissues that are well perfused. The second
consists of tissues for which distribution of drug is time dependent. In determining the
loading dose, the desired serum concentration should be multiplied by the volume of
the central compartment to avoid toxic levels.

20. Which fact must be considered when evaluating a patient who displays signs of drug
toxicity?
A. Drug metabolites (e.g., N-acetylprocainamide) may need to be measured as well as parent
 drug
B. If the concentration of total drug is within therapeutic limits, the concentration of free drug
cannot be toxic
C. If the drug has a wide therapeutic index, then it will not be toxic
D. A drug level cannot be toxic if the trough is within the published therapeutic range
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
21. When a therapeutic drug is suspected of causing toxicity, which specimen is the most
appropriate for an initial investigation?
A. Trough blood sample
B. Peak blood sample
C. Urine at the time of symptoms
D. Gastric fluid at the time of symptoms
Chemistry/Select course of action/Therapeutic drug monitoring/3
22. For a drug that follows first-order pharmacokinetics, adjustment of dosage to achieve
the desired blood level can be made by using which formula?
A. New dose

B. New dose

C. New dose

D. New dose
Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug
monitoring/2
23. For which drug group are both peak and trough measurements usually required?
A. Antiarrhythmics
B. Analgesics
C. Tricyclic antidepressants
D. Aminoglycoside antibiotics
Chemistry/Select course of action/Therapeutic drug monitoring/2

Answers to Questions 20–23

20. A Altered drug pharmacokinetics may result in toxicity even when the dose of drug is
within the accepted therapeutic range. Two common causes of this are the presence of
unmeasured metabolites that are physiologically active and the presence of a higher
than expected concentration of free drug. Because only free drug is physiologically
active, decreased binding protein or factors that shift the equilibrium favoring more
unbound drug can result in toxicity when the total drug concentration is within the
therapeutic range. Some drugs with a wide therapeutic index are potentially toxic
because they may be ingested in great excess with little or no initial toxicity. For
example, acetaminophen overdose does not usually become apparent until 3 to 5 days
after the overdose. This creates the potential for hepatic damage to occur from
 continued use, especially in patients who have decreased hepatic or renal function
because the drug half-life is extended.
21. B When a drug is suspected of toxicity, the peak blood sample (sample after absorption
and distribution are complete) should be obtained because it is most likely to exceed
the therapeutic limit. If the peak level is above the upper therapeutic limit, then toxicity
is confirmed, and the drug dose is lowered. If the peak drug concentration is within the
therapeutic range, toxicity is less likely but cannot be ruled out. A high concentration
of free drug, the presence of active metabolites, and abnormal response to the drug are
causes of drug toxicity that may occur when the blood drug level is within the
published therapeutic range.
22. A Most drugs follow first-order pharmacokinetics—that is, the clearance of drug is
linearly related to the drug dose. The dose of such drugs can be adjusted by
multiplying the ratio of the current dose to blood concentration by the desired drug
concentration, provided the blood concentration is measured at steady state.
23. D Aminoglycoside antibiotics cause damage to the eighth cranial nerve at toxic levels,
resulting in hearing loss. When given at subtherapeutic doses, they fail to resolve
infection. Most drugs falling in the other classes have a narrow peak–trough difference
but are highly toxic when blood levels exceed the therapeutic range. Usually, these can
be safely monitored by measuring trough levels.

24. Which of the following urine samples should be accepted for testing when processing
samples for drugs of abuse (DAUs)?
A. Urine of abnormal color
B. Urine with an abnormal odor
C. Container with seal not applied across the lid
D. Sample with a volume of 50 mL
Chemistry/Apply principles of special procedures/Sample Collection/Drugs/2
25. The enzyme-multiplied immunoassay technique (EMIT) for DAUs uses an:
A. Antibody conjugated to a drug
B. Enzyme conjugated to an antibody
C. Enzyme conjugated to a drug
D. Antibody bound to a solid phase
Chemistry/Apply principles of special procedures/Biochemical theory and principles/2
26. Which statement about EMIT is true?
A. Enzyme activity is inversely proportional to drug level
B. Formation of NADH is monitored at 340 nm
C. ALP is the commonly used conjugate
D. Assay use is restricted to serum
Chemistry/Apply principles of special procedures/Biochemical theory and principles/2
27. Which statement regarding cloned enzyme donor immunoassay (CEDIA) is true?
A. The enzyme used is G-6-PD
B. The enzyme donor and acceptor molecules are fragments of β-galactosidase
C. Drug concentration is inversely related to fluorescence
D. The antibody is covalently linked to the enzyme donor
 Chemistry/Apply principles of special procedures/Biochemical theory and principles/2

Answers to Questions 24–27

24. D Adulteration is a common problem with samples submitted for DAU testing.
Approximately 8% of the U.S. population has reported using an illegal drug at some
time, and approximately five per 1,000 samples submitted for testing are adulterated.
Urine with a volume under 30 mL, abnormal color, odor, or sign of adulteration should
be rejected. The label should be placed across the entire lid so that the seal would be
broken if the lid were removed after collection. A temperature strip should be affixed
to the container and read within 4 minutes of collection, and the temperature should be
written on the custody control form. Temperature outside the range of 90oF to 100oF is
cause for rejection.
25. C In EMIT, enzyme-labeled drug competes with drug in the sample for a limited
amount of reagent antibodies. When antibody binds to the enzyme–drug conjugate, it
blocks the catalytic site of the enzyme. Enzyme activity is directly proportional to
sample drug concentration because the quantity of unbound drug–enzyme conjugate
will be highest when drug is present in the sample.
26. B EMIT is a homogeneous immunoassay—that is, free antigen does not have to be
separated from bound antigen. Most EMIT assays use a two-reagent system. Reagent
A contains substrate (usually glucose-6-PO4), coenzyme (NAD+), and antibody to the
drug. Reagent B contains enzyme-labeled drug (usually G-6-PD-drug) and buffer. The
rate of NADH production is proportional to the drug concentration. EMIT assays are
commonly used to test for drugs of abuse in urine. In such cases, the enzyme activity
of the low calibrator (drug concentration equal to U.S. Substance Abuse and Mental
Health Services Administration minimum for a positive test) is used as the cutoff.
27. B CEDIA is a homogeneous enzyme immunoassay that is commonly used to measure
DAUs. Drug conjugated to a fragment of β-galactosidase that is catalytically inactive
competes with drug in the sample for a limited number of antibodies to the drug. The
fragment, called the enzyme donor (ED), and the substrate (chlorophenol red-β-D-
galactopyranose) are mixed with the sample. A second reagent containing monoclonal
antibody and a second fragment of β-galactosidase, called the enzyme acceptor (EA), is
added. If the antibody is neutralized by drug from the sample, the ED and the EA
combine to form an active enzyme. The concentration of drug in the sample is directly
proportional to the amount of chlorophenol red formed.

28. Which statement is true regarding particle-enhanced turbidimetric inhibition

immunoassay methods for therapeutic drugs?
A. Drug concentration is proportional to light scatter
B. Magnetic separation is needed to remove unbound conjugate
C. When particle-bound drug binds to antibody, light scattering is increased
D. Two antibodies to the drug are needed
Chemistry/Apply principles of special procedures/Biochemical theory and principles/2
29. Quantitation of a drug by GC-MS is usually performed in which mode?
A. Total ion chromatography
 B. Selective ion monitoring
C. Ion subtraction
D. Selective reaction monitoring
Chemistry/Apply principles of special procedures/Chromatography/1
30. SITUATION: A urine sample is received in the laboratory with the appropriate custody
control form and a request for DAU screening. Which test result would be cause for
rejecting the sample?
A. Temperature after collection 95°F
B. pH 5.0
C. Specific gravity 1.005
D. Creatinine 5 mg/dL
Chemistry/Evaluate laboratory data to detect sources of error/Toxicology/3

Answers to Questions 28–30

28. C Particle-enhanced turbidimetric inhibition immunoassays are homogeneous
immunoassays frequently used to measure proteins and therapeutic drugs in serum or
plasma. Polystyrene-modified latex particles conjugated to the drug (particle-bound
drug) compete with the drug in the sample for a limited number of antibodies. If drug
concentration is low, more of the antibody binds to the particle-bound drug, increasing
the turbidity of the reaction. Therefore, light scattering is inversely proportional to the
drug concentration.
29. B Most GC-MS instruments use an electron beam to split the drug emerging from the
column into its component ions. These are drawn into the mass analyzer, usually a
vacuum chamber containing two pairs of charged rods (a positive pair and a negative
pair), called a quadrupole analyzer. By changing the potential and RF applied to the
rods, the travel of ions will vary, depending on their m/z ratio. As ions emerge from
the mass filter, they are detected by an electron multiplier tube. CG-MS instruments
can be operated in two modes, total ion chromatography (TIC) and SIM. TIC displays
the retention time of all ions detected and their abundance. It is primarily used for
identification of unknown compounds. SIM measures the abundance of one or more
principal ions that provide sufficient specificity to eliminate potential interfering
substances and greater quantitative sensitivity. For example, tetrahydrocannabinol
(THC) can be identified by ions with an m/z ratio of 371.3, 372.3, and 473.3.
30. D Approximately five per 1,000 urine samples received for DAU testing have been
adulterated through either dilution, substitution, or addition of substances, such as
glutaraldehyde, which interfere with testing. The majority of these situations can be
detected by determining temperature (90°F–100°F) pH (4.5–8.0), specific gravity
(1.003–1.019), and creatinine (20 mg/dL or greater). All of the values listed are within
the limits of an acceptable sample, with the exception of creatinine. Dry reagent strips
that test for pH, specific gravity, creatinine, nitrite, peroxide, pyridinium, and
glutaraldehyde are available.

31. Which substance has the longest detection time in urine?

A. Amphetamines
 B. Cocaine
C. Benzodiazepines
D. Marijuana
Chemistry/Apply knowledge of fundamental biological characteristics/Drugs of abuse/1
32. Which statement about the measurement of carboxyhemoglobin is true?
A. Treatment with alkaline dithionite is used to convert carboxyhemoglobin to
oxyhemoglobin
B. Oxyhemoglobin has no absorbance at 540 nm, but carboxyhemoglobin does
C. Polychromic analysis is used to eliminate interference by oxyhemoglobin
D. Carboxyhemoglobin can be measured by potentiometry
Chemistry/Apply principles of special procedures/Carboxyhemoglobin/2
33. Which of the following statements about blood alcohol measurement is correct?
A. Symptoms of intoxication usually begin when the level exceeds 0.05% weight per volume
(w/v)
B. The skin puncture site should be disinfected with isopropanol
C. The reference method is based upon enzymatic oxidation of ethanol by ADH
D. GC methods require extraction of ethanol from serum
Chemistry/Apply principles of special procedures/Ethanol/2

Answers to Questions 31–33

31. D Some drugs have a long half-life and can be detected for longer periods after use, but
the detection window also depends on other variables, such as dosage, frequency of
use, and method sensitivity. Marijuana is stored in fatty tissue and is metabolized
slowly. In persons who use marijuana several times per week, cannabinoids can be
detected several weeks after last use. For chronic daily users, this extends to months
after discontinuation. Other drugs with detection windows of a week or more include
long-acting barbiturates, lysergic acid diethylamide (LSD), anabolic steroids, and
phencyclidine (PCP).
32. C The absorbance spectra of oxy- and carboxyhemoglobin pigments overlap, and
bichromatic or polychromatic analysis is required to accurately measure
carboxyhemoglobin concentration. In bichromatic analysis, oxyhemoglobin and
methemoglobin are converted to deoxyhemoglobin by the addition of alkaline sodium
dithionite. The ratio of absorbance at 541:555 nm is directly proportional to
carboxyhemoglobin concentration. Percent carboxyhemoglobin is commonly
determined from simultaneous absorbance measurements at 548, 568, and 578 nm, or
other wavelength combinations, a process called oximetry.
33. A ADH is not specific for ethanol, and in vitro interference can occur with some ADH
methods when skin is disinfected with other alcohols. For this reason, and to avoid
interference with the interpretation of chromatograms for volatiles, blood samples are
collected after disinfecting the skin site with benzalkonium chloride or other
nonalcohol antiseptic. GLC is the legally accepted method of ethanol analysis. The low
boiling point of ethanol permits direct analysis on blood or plasma diluted with water
containing 1-propanol or other suitable internal standard.
34. Which specimen is the sample of choice for lead screening?
A. Whole blood
B. Hair
C. Serum
D. Urine
Chemistry/Apply principles of special procedures/Lead/1
35. Which of the following enzymes can be used to measure plasma or serum salicylate?
A. Peroxidase
B. Salicylate esterase
C. Salicylate hydroxylase
D. p-Aminosalicylate oxidase
Chemistry/Apply principles of special procedures/Toxicology/1
36. Which of the following tests is least essential to the operation of an ED at a general
hospital?
A. Carboxyhemoglobin
B. Osmolality
C. Salicylate
D. Lead
Chemistry/Select tests/Toxicology/2

Answers to Questions 34–36

34. A Lead accumulates in RBCs, bones, and neural tissues; whole blood, hair, and urine
are suitable for demonstrating lead toxicity. The greatest sensitivity is obtained by
using whole blood, which can detect exposure over time. Because lead is rapidly
eliminated from plasma, serum or plasma should not be used to test for lead exposure.
Lead binds to sulfhydryl groups of proteins, such as delta-aminolevulinic acid (Δ-
ALA) dehydratase and ferrochelatase and interferes with heme synthesis. This results
in increased free erythrocyte protoporphyrin, erythrocyte zinc protoporphyrin, urinary
coproporphyrin III, and Δ-ALA, which are also useful markers for lead poisoning.
When screening for lead poisoning in children, the method of choice is graphite
furnace atomic absorption spectrophotometry or ICP-MS because these methods offer
the best analytical sensitivity. The Centers for Disease Control and Prevention (CDC)
cutoff for acceptable whole blood lead level in children is less than 5.0 µg/dL.
35. C The enzymatic assay of salicylate uses salicylate hydroxylase, which reduces
salicylate with NADH and forms catechol and NAD+. Salicylate can also be measured
by HPLC and various immunoassays, including EMIT. Salicylate toxicity causes an
initial respiratory alkalosis because the drug stimulates the respiratory center.
However, this is followed by metabolic acidosis as the drug is metabolized. Therefore,
it is imperative to identify salicylate as the cause of toxicity before treatment of an
acid–base imbalance caused by aspirin overdose.
36. D The vast majority of acute toxicology situations seen in the ED involve poisoning
with alcohol, acetaminophen, salicylate, abuse substances, or CO poisoning, and at a
minimum, EDs should offer tests for these. In the absence of specific tests for DAUs or
a comprehensive drug screen, serum osmolality measured by freezing point depression
 is a sensitive surrogate test for drug and alcohol overdose. In the ED environment a
difference between measured and calculated osmolality greater than 10 mOsm/kg
almost always indicates drug or alcohol poisoning. Toxicity from lead poisoning and
most other trace metals is usually a chronic condition that does not often require
immediate access to laboratory testing.

37. Which of the following trace elements is considered an essential micronutrient?

A. Thallium
B. Aluminum
C. Mercury
D. Selenium
Chemistry/Apply knowledge of fundamental biological characteristics/Trace metals/1
38. When measuring trace metals other than lead in blood, what type of tube should be
used?
A. Navy blue top
B. Green top
C. Purple top
D. Red top
Chemistry/Identify standard operating procedures/Specimen collection and handling/1
39. Which whole blood level is suggestive of excessive exposure to lead in children but not
adults?
A. 4 µg/dL
B. 14 µg/dL
C. 28 µg/dL
D. 32 µg/dL
Chemistry/Evaluate data to recognize health and disease states/Lead/2
40. What are the likely laboratory findings in a person suspected of having Wilson disease?
A. Blood copper and ceruloplasmin low, urinary copper excretion high
B. Blood and urine copper concentration high, ceruloplasmin low
C. Blood and urine copper concentration high, ceruloplasmin high
D. Blood and urine copper concentration low, ceruloplasmin low
Chemistry/Correlate laboratory results/Metals/2

Answers to Questions 37–40

37. D Trace elements can be divided into two categories: those that have no known
biological purpose and those that do. The former include thallium, mercury, lead,
cadmium, and aluminum. All others can be considered essential trace elements,
including arsenic that has been shown to be necessary for normal methionine
metabolism. Most trace elements are of medical importance because excessive levels
lead to toxicity. However, a deficiency of trace elements, such as selenium, zinc, and
copper, are commonly caused by total parenteral nutrition and is medically important.
38. A To avoid trace contamination by metals present in the stopper lubricants, a tube with a
navy blue top is used for measuring trace metals other than lead. These tubes are
validated for most but not all trace metals. Such tubes are available with or without
 EDTA for whole blood or serum analysis, respectively. Tubes with tan stoppers
containing EDTA are used for lead assay because they are certified to contain no more
than 0.25 µg/dL lead. In addition, type 1 purity water (10 Mohm, 10 or less CFU/mL)
and analytical reagent grade chemicals are always used to prepare reagents, such as
matrix modifiers. Although most trace metals are measured in whole blood or serum,
arsenic is usually measured in urine because it is metabolized and excreted within
hours of ingestion.
39. B Because lead exposure in children leads to learning impairment, the cutoff for
exposure recommended by the CDC is 5 µg/dL in venous whole blood. Values of 5
µg/dL or more should be monitored closely with follow-up testing, and if they
increase, steps should be taken to remove lead contamination from the home and the
environment. For adults the recommended cutoff is 25 µg/dL. Because lead readily
enters the RBCs and passes from plasma to urine quickly, whole blood is a more
sensitive measure of exposure, rather than plasma. Because lead from the fingers may
contaminate the specimen, a venous sample is preferred over a capillary sample
collected by finger stick.
40. A Wilson disease is an autosomal recessive disease in which copper transport is
abnormal. The gene causing the disease codes for an adenosine triphosphatase
(ATPase, called Wilson protein or ATP7B) that is needed to excrete copper into bile
and incorporate copper into ceruloplasmin. There are over 200 reported mutations of
this gene. Absence of Wilson protein results in failure to load ceruloplasmin with
copper, dramatically reducing its half-life in blood. Therefore, blood levels of
ceruloplasmin are low, and blood levels of copper are usually low because there is
little ceruloplasmin to bind it. Copper deposits in tissues, particularly the liver and
brain, causing necrosis, and urine levels are elevated.