[Fan Favorite] Laboratory Data Interpretation

As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

A  45-year-old woman with no chronic health problems presents a 6-month history increasing fatigue despite adequate opportunity for rest , worsening dry skin and increased menstrual flow volume. In analyzing the laboratory data below, which is most consistent with the diagnosis of hypothyroidism?

A. TSH <0.15 mIU/L (0.4–4.0 mIU/L), free T4=79 pmol/L (10–27 pmol/L)

B. TSH=8.9 mIU/L (0.4–4.0 mIU/L), free T4=15 pmol/L (10–27 pmol/L)

C. TSH=1.9 mIU/L (0.4–4.0 mIU/L), free T4=22 pmol/L (10–27 pmol/L)

D. TSH=64 mIU/L (0.4–4.0 mIU/L), free T4=3 pmol/L (10–27 pmol/L)
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Transcript

Welcome to NP Certification Q&A presented by Fitzgerald Health  Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.  

 Sandra is a 72-year-old with hypertension who's on an appropriate dose of an ACE inhibitor with adherence. Today's BP = 152 / 96 and she is without HTN-related complaint. Physical exam is unremarkable. She has a history of well-controlled asthma and is using ICS/LABA therapy. Due to osteoarthritis, she reports, “I get up slowly. Sometimes I do not get the bathroom on time, and I lose my urine control.”  

Which of the following represents the next best step in Saundra’s therapy?   

A. Advise that her BP is in an acceptable range. Remember, it was 152/96. 

B. Thiazide diuretic therapy should be initiated. 

C. Add a calcium channel blocker to her current therapy. 

or 

D. A beta blocker represents the optimal additional therapy.  

Where do you start? 

Next, you're going to determine what kind of question this is. 

We're told the patient has a diagnosis of hypertension. It says she has high blood pressure. She has high blood pressure. And the patient is being treated. As a result, this is an evaluation question because what we're looking for is response to therapy and evaluation critical component about this is whether you stay the course with current therapy or adjust therapies because the patient is not meeting best practices, treatment goals. 

 So let's take a look at the information presented and how it relates to the question choices provided.  We're being told that she's adherent and taking an appropriate dose of anti hypertensive med, right? If you're being told the patient is taking their med properly and they're on an appropriate dose, those two pieces of information are in fact true.  

I understand sometimes in practice we'll have patients say, "Oh yeah, I take my med every day," and then you discover later on that they're actually not taking it. On the boards, if it says a patient is adherent with therapy, they're adherent with therapy. And that's a fact. And it's an important part of the data given to you about this patient. We can't blame her high blood pressure on the fact that she's not taking her medication. 

She has no evidence of acute or chronic hypertensive target organ dysfunction or TOD, given the negative history, we're told she has no hypertensive-related complaints, no visual changes, no shortness of breath, etc., and her physical exam is within normal limits. So, that would rule out hypertensive retinopathy, particularly low-grade hypertensive retinopathy like grade 1, is very common in people whose blood pressure is not well controlled. And she has no S4 heart sound, another pathologic finding in a person with poorly controlled type blood pressure. 

Her asthma is well-controlled on current medication. What we have to keep in mind here is she has, albeit well-controlled, she none-the-less has established lower airway disease. And that could impact our choice of an antihypertensive med. 

 However, we really do need to listen up. This woman has osteoarthritis that is contributing to issues of functional urinary incontinence. She's a little slow getting out of the chair. Sometimes she loses her urine because she just can't hop up quickly enough to get to the bathroom. 

 We don't want to give her a medication that could worsen the possibility of urine loss. 

Now, I know I even read this question and I say to myself and I want to help her with her OA, we're not asked we're not being asked about that. That's another visit to another visit another day. But it is important that what she's telling you is: I have a mobility issue that leads to me losing urine, that qualifies as functional urinary incontinence.  

Let's go back and take a look at the options here. 

A.  Advise that her blood pressure is in an acceptable range. Clearly, that is not true because evidence-based practice dictates that her blood pressure is not at goal, as in most patients with mildly elevated blood pressure. Well, this needs to be addressed. She has no evidence accelerated hypertensive TOD. In other words, that's one way of saying this is not an emergency situation. Yes, something needs to be done about it, but it's not an emergency.  

Option B. Thiazide diuretic therapy should be initiated. Well, where as the thiazide diuretics are a wonderful wonderful class of meds for the treatment of high blood pressure and are also often are first line meds or are an add-on med to a person who's being treated for high blood pressure when hypertensive control has not been achieved a single drug. Keep in mind this is a woman with functional urinary incontinence. Adding a diuretic might worsen that. There is the adage, first do no harm. You don't want to make her have more urine accidents because if that happens, guess what she's going to do? She's going to stop taking that Thiazide diuretic. So that's a good example of a medicine that would beautifully take care of the blood pressure issue I am sure, but then exacerbate a chronic health problem. 

Option C. Add a calcium channel blocker to her current therapy. That is the best answer, most reasonable choice. It's going to bring her blood pressure down nicely. It is mentioned favorably in both JNC-8 and ACC/AHA guidelines as among the first medications we use for the treatment of high blood pressure. Commonly an add-on med in a situation like this. 

Option D. Beta blocker represents the optimal additional therapy. Given that this med class does not provide significant blood pressure lowering effects compared to the ACE inhibitors, the thiazide diuretics, and the calcium channel blockers, the beta blockers are not among the first-line antihypertensive meds. We're either starting or for first add-on therapy. Beta blocker therapies are typically reserved for people with high blood pressure when there is a presence of additional co-morbidities, it is such as heart failure or ASCVD. In addition, the use of this med class, particularly non-cardioselective options like propranolol, can contribute to worsening airway obstruction. 

 Key takeaway, all the information provided in the narrative of the question contribute to finding the best, not just the correct answer to this question. Technically, thiazide diuretic and calcium channel blocker were both correct, but calcium channel blocker was the best answer for this patient.  

Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com.