PaEasy Endocrine TEST BANK, Questions and answers. Rated A+ A 40-year-old female presents to your office with symptoms of weight gain, hirsuitism, and easy bruising. Past medical and surgical his... tory is noncontributory. She drinks one glass of wine on weekends and does not smoke cigarettes. She takes one multivitamin daily. Upon physical exam, you note facial fullness, central obesity, and thin skin. Which of the following is the most common cause of her symptoms? A. Pituitary Adenoma B. Iatrogenic C. Adrenal Micronodular Hyperplasia D. Adrenocortical adenoma E. Ectopic ACTH syndrome - ✔✔Pituitary adenoma The correct choice is A, pituitary adenoma. This patient's clinical presentation is typical in Cushing's syndrome. The most common cause of Cushing's syndrome (other than ingestion of oral steroid medications) is Cushing's disease. This disease is caused by a benign, ACTH secreting pituitary adenoma. Choice B, iatrogenic, refers to the ingestion of prescribed (or non-prescribed) oral corticosteroid medications. This is frequently seen in patients requiring long-term oral steroid medications. This patient does not have this type of history. Choice C, adrenal micronodular hyperplasia, and choice D, adrenocortical adenoma, can cause Cushing's syndrome at less frequent incidence. Choice E, ectopic ACTH syndrome, presents more commonly in males with extremely elevated levels of plasma cortical and ACTH. These patients commonly have a positive history of an ectopic source of the ACTH, such as in small cell carcinoma of the lung. A patient is recovering from having a total thyroidectomy two days ago for medullary thyroid cancer. An extensive neck dissection was required during the surgery. Post-operative lab testing reveals a low serum calcium level. Which of the following clinical presentations will most likely occur in this patient? A Constipation B Anorexia C Polyuria D Bone pain E Paresthesias - ✔✔Paresthesias The correct choice is E, paresthesias. Circumoral paresthesias are signs of hypocalcemia. Hypocalcemia can occur after any type of neck surgery that may have resulted in destruction of the parathyroid glands. Choices A through D are symptoms of hypercalcemia and may be seen in hyperparathyroidism. A 49-year-old man presents to the office complaining of general malaise with muscle aches, anorexia, fever, and severe pain over his anterior neck radiating to his ears. He states that he was ill about 2 weeks ago with a sore throat, but it resolved within a few days. On palpation, the thyroid gland is enlarged and tender. His laboratory workup shows a high T4 level and increased erythrocyte sedimentation rate (ESR). What is the most appropriate therapy for this patient's disease? A levothyroxine sodium B PTU therapy C radioiodine ablation D surgery E supportive therapy only - ✔✔Supportive therapy only This is subacute, painful thyroiditis. This is a self-limiting disorder that at most requires symptomatic therapy. In mild cases, analgesics (ASA) are sufficient for pain relief and to decrease the inflammation. Prednisone may bring more relief if needed. Transient hypothyroidism should be treated as well. An extremely heavy 12-year-old girl comes to the practice with her grandmother for new patient evaluation, bringing old records with her. Her blood pressure today is mildly elevated. Which of the following parameters will help determine whether her overweight and elevated blood pressure are due to Cushing syndrome (adrenocortical hyperfunction) rather than exogenous obesity? A advanced skeletal maturity B heavy thighs and legs C pinkish striae D short stature E slightly increased growth rate - ✔✔short stature Children with Cushing syndrome typically have short stature, while those who are obese due to exogenous factors have normal or tall stature. Likewise, they tend to have delayed skeletal maturity (A), truncal obesity with thin extremities (B), purplish striae (C), and a slowed growth rate (E), while obese children have advanced maturation, heavy extremities, pinkish striae, and an increased growth rate. A 29-year-old woman presents in July to your office with symptoms of palpitations, sore neck, and excessive sweating, despite using her air conditioner all the time. No surgical or trauma history is noted. She is currently not taking any medications. Vitals include the following: BP = 124/68, pulse = 110 beats per minute, respirations = 18 per minute, and temperature = 101 o F orally. Upon exam, her thyroid is mildly enlarged without nodules, and severely tender. No local erythema or heat is noted. Which of the following lab results would you expect in this patient? A Serum total T4 level = 5.0 ug/dL B Serum TSH level = 0.25 uIU/mL C Sedimentation rate = 15 mm/hr D Free thyroxine index = 8.0 E Positive thyroid stimulating antibodies - ✔✔B Serum TSH level = 0.25 uIU/mL The correct choice is B, Serum TSH level=0.25 uIU/mL. The reference range for TSH is 0.34 to 4.25 uIU/mL, and therefore the level in this patient is low. This patient is presenting with signs and symptoms of hyperthyroidism, most likely due to subacute thyroiditis. The leaking of thyroid hormone into the circulation causes anterior pituitary suppression and reduced TSH secretion. Choice A is seen in patients with hypothyroidism. Choice C is within the reference range for woman. Since subacute thyroiditis is an acute inflammatory disorder, patients with this disorder will commonly present with an elevated sedimentation rate. Choice D corresponds to a euthyroid situation. It is an estimate of the free thyroid hormone level in the plasma. This result is within the reference range. Choice E is not seen in subacute thyroiditis. They are commonly found in patients with Graves' disease. A 5-year-old girl is seen in your office with a several week history of increased thirst, weight loss, and blurred vision. She has a positive family history for diabetes mellitus, hypertension, and stroke. Her urine dipstick chemical testing reveals positive glucose and negative ketones, protein, blood, and nitrites. Which of the following laboratory test results would support a diagnosis of diabetes mellitus in this patient? A random plasma glucose > 200 mg/dL B random urine glucose dipstick > 1+ C plasma hemoglobin A1c < 7% D fasting plasma glucose > 110 mg/dL E 2-hour postprandial plasma glucose > 135 mg/dL - ✔✔random plasma glucose > 200 mg/dL One of your patients is requesting your help. He has seen three physicians in the past 3 months and is still having symptoms. He states, "I keep having these episodes of feeling like I am going to die. Out of the blue I feel real nervous, I get a splitting headache, break out in a sweat, and even feel like I am trembling. Sometimes I feel my heart beating out of my chest but don't have any pain or shortness of breath." He has had numerous tests including a cardiac stress test, multiple EKGs, complete blood count (CBC), basic metabolic panel (BMP), thyroid tests, and computed tomography (CT) scans of his head, which were normal. His last physician told him that he had an anxiety disorder and should try medications; he declined. His only medical problem is hypertension, which has worsened recently. He is currently taking lisinopril 20 mg QD, amlodipine 10 mg QD, and HCTZ 25mg QD. His physical examination is unremarkable except a BP of 190/92, P = 74. What is the best test to order to confirm your suspected diagnosis? A dexamethasone suppression test B sleep study C renal artery ultrasound D plasma fractionated free metanephrines E thyroid uptake scan - ✔✔he correct answer is (D). The patient's symptoms and uncontrolled hypertension with a previous negative evaluation for cardiac, electrolyte, or thyroid causes highly suggests a pheochromocytoma as the possible cause. Plasma fractionated free metanephrines is a very sensitive test for the diagnosis of pheochromocytoma. Another test to consider would be evaluation of the total urinary metanephrines. A dexamethasone suppression test, choice (A), is used to r/o Cushing's syndrome, which is unlikely due to the normal physical examination findings. A sleep study, choice (B), (suggesting sleep apnea) and renal artery ultrasound, choice (C), (suggesting renal artery stenosis) are used to diagnose secondary hypertension, but would unlikely explain all the symptoms in the scenario. A thyroid uptake scan, choice (E), is not indicated since there is no indication of abnormal thyroid testing suggesting hyperthyroidism, or examination stated findings suggestive of a thyroid nodule. What is the definitive treatment for the majority of patients presenting with mild symptoms of hyperthyroidism secondary to subacute thyroiditis? A Subtotal thyroidectomy B Oral methimazole C Symptomatic treatment D Radioactive iodine E Antibiotics - ✔✔Symptomatic treatment The correct choice is C, symptomatic treatment. Most patients with subacute thyroiditis and symptoms of hyperthyroidism require only symptomatic treatment, with non-steroidal anti-inflammatory medications and/or beta blockers, for any cardiac symptoms including palpitations and tachycardia. Occasionally, patients may require a course of prednisone for this acute inflammatory condition. Most patients will recover spontaneously within a few months. Choices A, B, D, and E are not necessary in this condition. Most cases of subacute thyroiditis are associated with viral infections, and resolve without additional thyroid medications. A 12-year-old boy is being seen for concerns of development of breast tissue. Upon physical exam, he is noted to have a firm, slightly tender mass under the left areola. What is the most appropriate action at this time? A referral to pediatric surgery for resection B measurement of serum hCG C measurement of testosterone and estrogen levels D reassurance and observation - ✔✔reassurance and observation Type 1 idiopathic gynecomastia in adolescent men presents with a firm mass under the areola ("breast bud") typically during sexual maturation stages (SMR), stages II to III. This is a result of normal estrogen and androgen activity at the breast tissue level. Appropriate action is observation and to reassure the patient that the condition will likely resolve in 1 to 2 years. A patient seen at the prenatal clinic develops Graves disease at 25 weeks' gestation. Which of the following is the most appropriate treatment? A PTU 100 mg po tid B methimazole 10 to 30 mg po qd C propranolol 80 mg po qid D radioactive iodine therapy (RAI, 131I) E levothyroxine 0.1 mg po qd - ✔✔PTU 100 mg po tid In nonpregnant patients, PTU and methimazole are the drugs of choice for the management of Graves disease. During pregnancy, PTU has a lower incidence of crossing the placental barrier than does methimazole. It also is excreted into breast milk to a lesser degree than is methimazole. Propranolol will help with the symptoms of Graves but not treat it. It can also cause low birth weight in the infant. RAI is contraindicated in pregnancy. Levothyroxine will worsen a Graves patient's hyperthyroidism A 28-year-old woman who was born and brought up just outside of Washington, DC, comes in for evaluation of vague "problems with swallowing." She has no other symptoms except "my neck is bigger than it used to be." Examination reveals only a diffuse, somewhat irregular, nontender enlargement of the thyroid gland with distinct masses palpable within it. What is the most likely diagnosis? A endemic goiter B Graves disease C Hashimoto thyroiditis D multinodular goiter E thyroid carcinoma - ✔✔Multinodular goiter Multinodular goiter is the most likely in a woman with these findings in the United States. It may be nontoxic as in this case or toxic, i.e., producing excessive thyroid hormones which cause symptoms of hyperthyroidism. Endemic goiter (A), which may present as a simple enlargement of the thyroid or as a multinodular one, is found almost entirely in iodine-deficient areas of the world and is extremely rare in the U.S. In Graves disease (B), the thyroid is enlarged and may exhibit a thrill and a bruit. In addition, the patient would have other signs of hyperthyroidism. The thyroid in Hashimoto thyroiditis (C) is diffusely enlarged and firm with fine nodules. A thyroid carcinoma (E) usually presents as a firm, nontender nodule in the gland. A 56-year-old woman is being seen for regular assessment and monitoring of her type 2 diabetes mellitus. She has been following a strict diet and exercise plan for 2 years with the addition of metformin 6 months ago for an increased HgA 1c level. Her HgA 1c at today's visit is 7.1. What is the appropriate management for this patient? A add exenatide to her current therapy B change her oral therapy to rosiglitazone C add insulin to her current therapy D maintain her current therapy and recheck in 6 months - ✔✔maintain her current therapy and recheck in 6 months D The HgA 1c goal for this patient is less than 6.5, with action at a level of greater than 8.0. The appropriate action at this time is to continue her current therapy and reassess in 6 months. Your supervising physician asks you to advise him which finding is least likely to be suggestive of a thyroid malignancy in your 49-year-old female with a small palpable thyroid nodule. Which of the following choices would be least likely to suggest malignancy in this patient? A ultrasound showing lesion with microcalcifications B ultrasound showing a lesion of > 1 cm C hot nodule on 123I uptake scan D ultrasound showing a solid lesion E cold nodule on 123I uptake scan - ✔✔hot nodule on 123I uptake scan C The correct answer is (C). A hot nodule, which is a hyperfunctioning thyroid nodule, suggests a benign etiology. The other choices, including ultrasound findings of microcalcifications, solid lesions, and lesions > 1 cm, should increase your index of suspicion for possible malignancy. Cold nodules are nonfunctioning thyroid nodules, which should increase your suspicion, especially in combination with suspicious ultrasound and/or clinical examination findings. A 35-year-old male presents complaining of increasingly constant headaches, double vision centrally, and a progressive loss of peripheral vision for two weeks. He has no previous headache history and denies any other medical conditions. Physical examination reveals bitemporal hemianopsia without additional neurologic findings. What is the most likely diagnosis? A Acute ischemic stroke B Circle of Willis ruptured aneurysm C Migraine headache D Multiple sclerosis E Pituitary adenoma - ✔✔Pituitary adenoma Pituitary adenomas, benign neoplasms associated with pituitary hormone secretory changes, may enlarge and become symptomatic. Symptoms are based upon the location and size of the tumor, and may include bitemporal hemianopsia, double vision, color desaturation, and visual acuity loss. Headaches may occur, due to associated pressure changes within the intrasellar space. Additional evaluation should include a T1-weighted MRI, screening laboratory tests, and a full ophthalmologic evaluation. These tests will also help evaluate for potential differential diagnoses, such as those listed. The patient's history is not consistent with an acute ischemic stroke or migraine headache. Although an unruptured aneurysm may have very similar findings to a pituitary tumor, ruptured aneurysms present with acute headache, nausea, vomiting, and potential changes in consciousness. Multiple sclerosis (MS) should remain on the differential for this patient and will also be evaluated through MRI (although the current findings are more consistent with a pituitary adenoma), and additional neurologic findings would be likely with MS. A 63-year-old woman presents with shortness of breath, cough, and proximal muscle weakness of 1-month duration. On clinical exam, she is noted to have a blood pressure of 156/102 mm Hg, facial flushing, mild hirsutism, truncal obesity, marked proximal muscle weakness of both the upper and lower extremity, and hyperpigmentation over the palms and back of the neck. Laboratory exam reveals hypercortisolism and increased ACTH. Which of the following would be the most likely primary diagnosis in this patient? A lymphoma B ovarian cancer C renal cell carcinoma D small cell lung carcinoma - ✔✔Small cell lung cancer Tumor cells may secrete hormones that have the same biologic actions as the normal hormone. This patient's symptoms are consistent with adrenocorticoid hyperfunction. The most common cause of ectopic ACTH syndrome is small cell lung carcinoma. This should be suspected in any patient with risk factors for lung cancer. In addition to insulin and fluid replacement with 0.9% saline, which electrolyte is commonly infused in the type 2 diabetic patient who arrives in the emergency department in a hyperglycemic, hyperosmolar, nonketotic state? A bicarbonate B potassium C calcium D magnesium E sulfate - ✔✔potassium Insulin not only causes cellular uptake of glucose but also of potassium. Hypokalemia may develop when insulin is infused to correct either a hyperglycemic hyperosmolar state or a diabetic ketoacidosis. Hence, in order to avoid hypokalemia, potassium chloride can be added to a saline solution, as long as the serum potassium is not elevated. A new patient is seen in your internal medicine office today. She is coming in to request the removal of several skin tags. She is a 55-year-old woman with a history of untreated acromegaly. A health maintenance plan is set up with the patient, and includes a colonoscopy. This patient is at increased risk for which of the following findings on colonoscopy? A Anal fissures B Ulcerative colitis C Colon polyps D Pseudomembranous colitis E Colonic fistulas - ✔✔Colon polyps The correct choice is C, colon polyps. Approximately 30% of patients with acromegaly have been found to have colon polyps. These patients also have an increased risk of colon cancer. Patients with acromegaly have not been found to be at increased risk for the other response choices listed here. A 53-year-old man is taking a proton pump inhibitor for GERD symptoms, a beta blocker and a thiazide diuretic for hypertension, an SSRI for depression, and an over-the-counter NSAID as needed for aches and pains. He has developed gynecomastia and laboratory studies reveal an elevated prolactin level. If his hyperprolactinemai is due to one of his medications, which is the most likely cause? A the beta blocker B the NSAID C the proton pump inhibitor D the SSRI E the thiazide diuretic - ✔✔the SSRI Many medications cause hyperprolactinemia, including SSRIs, tricyclic antidepressants, and antipsychotics. Hydralazine and methyldopa, but not beta blockers (A), may also raise prolactin levels; likewise opioids, but not NSAIDS (B). Cimetidine and ranitidine, but not proton pump inhibitors (C) are included among possible pharmaceutical causes. Thiazide diuretics (E) are not know to raise prolactin levels. A 60-year-old man presented with a mass in the left lobe of the thyroid. Fine needle aspiration was consistent with papillary carcinoma. There was no evidence of locally invasive or metastatic disease. Which of the following treatments is recommended for this patient? A Chemotherapy B External beam radiation C Preoperative radioiodine ablation D Total thyroidectomy - ✔✔Total thyroidectomy Papillary carcinoma is the most common type of thyroid malignancy. Treatment includes a thyroid lobectomy and isthmusectomy or total thyroidectomy. The decision regarding the extent of the surgery is based on the extent of the disease, the tumor size, and histiologic grade. A poor prognosis is seen in males, patients older than 50 years of age, primary tumors greater than 4 cm in size, tumors that are less well differentiated, or evidence of locally invasive or metastatic disease. Accordingly, the recommended treatment for this patient is a total thyroidectomy. Radioiodine ablation is recommended postoperatively. Your patient returns to your office for a follow up for non-insulin-dependent diabetes mellitus (NIDDM). Her HgA1c in the office is 6.4%. She is concerned about developing kidney disease from her diabetes and requests that you test her for this. What initial screening test should you order that would provide clues to potential diabetic nephropathy allowing for treatment to slow the disease progression? A 24-hour urine for protein B serum BUN/CR C urine microscopic D urine microalbumin E serum protein - ✔✔urine microalbumin The correct answer is (D). An easy office dipstick or laboratory test for urine microalbumin should be done initially and periodically on diabetic patients who are at risk for diabetic nephropathy. Treatment should be initiated if microalbuminuria is found to slow disease progression. A urine microscopic for renal casts may be helpful if the patient has symptoms of kidney disease, but is not an initial screening test. Serum BUN/CR and GFR are useful tests for patients with known diabetic nephropathy to indicate the stage of chronic renal failure but is not elevated early in the disease progression, before urine microalbumin. A 24-hour protein is not indicated in this case as an initial screening test. A 78-year-old male returns to the FP office for a follow up of non-insulin-dependent diabetes mellitus (NIDDM) as a new patient to you, although he has been an office patient for the past year. He denies any problems this visit and says his blood sugars are in the 90-120 mg/dl range. He is currently taking the medications listed in the following choices. You receive his labs and note that his creatinine is 2.0 mg/dl and on the previous few labs this creatinine was also in the 1.8-2.0 mg/dl range. What medication should be discontinued? A glipizide B metformin C omeprazole D sitagliptin E atenolol - ✔✔metformin The correct answer is (B). Metformin is contraindicated in this diabetic patient with chronic renal failure due to an increased risk of lactic acidosis and should be discontinued. Sitagliptin requires a dosing adjustment in renal failure but is not contraindicated in this patient. Glipizide (sulfonylurea), omeprazole (a PPI for GERD), and atenolol (a beta blocker for hypertension) are not contraindicated in this patient. Beta blockers should be used with caution in diabetics due to the potential of masking symptoms of hypoglycemia, but are not contraindicated. A 30-year-old female presents to your office for a routine physical exam. She has not seen a health care provider in many years. Upon talking with the patient, you find out that she had been diagnosed with hypertension several years ago, but was unable to afford the antihypertensive medications that were prescribed to her. She has no complaints at this time. Upon exam of the head and neck, you note widened spaces between her lower incisor teeth and a large, fleshy nose. Her skin is oily and she demonstrates mild proximal muscle weakness. Her EKG reveals a left axis deviation and widened QRS. What is the most likely rationale for her clinical presentation? A Diabetes mellitus B Cushing's syndrome C Hypothyroidism D Acromegaly E Clinical depression - ✔✔Acromegaly The correct choice is D, acromegaly. Patients with acromegaly have an abundance of growth hormone secretion. This leads to excessive growth of many areas of the body including soft tissue. Patients with acromegaly also have an increased incidence of hypertension and left ventricular hypertrophy. None of the other choices will cause this patient's constellation of symptoms. Patients with many endocrine disorders may develop weaknesses as seen in this patient, but the large nose and widely spaced teeth are characteristic of acromegaly. A 62-year-old obese woman presents with progressive numbness and tingling in her feet for the past 3 months. On physical examination, the patient is found to have decreased sensation to pinprick and vibration, absence of ankle reflexes, and difficulty with tandem walking. Which is the most common etiology of her symptoms? A diabetes mellitus B alcoholism C vitamin B12 deficiency D spinal cord tumor E rheumatoid arthritis - ✔✔DM Peripheral neuropathy is a syndrome that is manifested by muscle weakness, paresthesias, decreased deep tendon reflexes, and autonomic disturbances most commonly in the hands and feet, such as coldness and sweating. There are many causes of peripheral neuropathy ranging from metabolic conditions to malignant neoplasm, rheumatoid arthritis, and drug and alcohol use. The increase in non-insulin-dependent diabetes mellitus due to obesity in the American population has increased the incidence of associated disease states A patient was prompted to visit his health care provider after his wife started to notice that he was not interested in eating, has lost weight, and has been suffering from nausea for the last few weeks. The practitioner notes hyperpigmentation of the patient's skin, although the patient denies any recent sun or tanning salon exposure. Routine non-fasting blood work reveals the following: Sodium = 130 meq/L Potassium = 5.2 meq/L Chloride = 105 meq/L Glucose = 135 mg/dL Hemoglobin = 13.0 g/dL Hematocrit = 39.0 WBC count = 8,000/mm 3 Which of the following physical exam findings would you expect to see in this patient? A Orthostatic hypotension B Wide, purple striae C Central obesity D Full facial features E Exophthalmous - ✔✔Orthostatic hypotension The correct choice is A, orthostatic hypotension. The first step in the discussion of this patient is the suspected diagnosis of adrenal insufficiency. Patients with this disorder will have an excess of ACTH, which will act like melanocyte stimulating factor on the skin and cause hyperpigmentation. In adrenal insufficiency, aldosterone is deficient, thereby causing a decrease in sodium retention and potassium excretion. Hypotension is found in approximately 90% of these patients, sometimes associated with syncope as well. Choices B, C, and D are found in patients with cortisol excess. Choice E can be found in patients with Graves' disease. Over a period of several months, a 62-year-old man has developed erectile dysfunction. He has no history of neurologic, kidney, or cardiovascular disease or diabetes mellitus. He takes a multivitamin and an occasional ibuprofen for aches and pains. He has never smoked cigarettes, drinks 1-2 glasses of wine with dinner on weekends, and uses no mind-altering drugs. Physical examination is remarkable only for bilateral gynecomastia. What is the most likely diagnosis? A breast cancer B depression C prolactinoma D steroid abuse E testicular cancer - ✔✔Prolactinoma Men with prolactinomas may experience erectile dysfunction, infertility, and, less commonly, gynecomastia. Breast cancer in men (A) presents as a usually as a unilateral mass. Men with depression (B) may have erectile dysfunction, but not gynecomastia. Steroid abuse (D) is associated with gynecomastia, but the patient would likely be showing other signs and symptoms. Testicular cancer (E), specifically germ cell cancer, is associated with gynecomastia in 5% of cases but this man has no testicular mass or swelling. Patients with suspected familial hypercholesterolemia have serum cholesterol levels > 300 mg/dL and are at increased risk of atherosclerosis. Which of the following physical exam findings are nearly pathognomonic for familial hypercholesterolemia? A Tendon xanthomas B Lipomas C Bouchard's nodes D Carotid bruits E Visceral obesity - ✔✔Tendon xanthomas The correct choice is A, tendon xanthomas. These are depositions of cholesterol rich substances that can present in any tendon as a mass-like lesion. They are most commonly found in the Achilles, patellar, and hand extensor tendons. Choice B, lipomas, are benign, soft, moveable subcutaneous tumors made from fat cells. Choice C, Bouchard's nodes, are painless nodules on the PIP joints, commonly seen in patients with osteoarthritis. Choice D, carotid bruits, may be heard with auscultation of the neck during the physical exam in patients with artherosclerosis of the carotid arteries. Choice E, visceral obesity, is a risk factor for diabetes and atherosclerosis, but is not pathognomonic of familial hypercholesterolemia. A mother expresses concern for her teen son after feeling a lump in his neck. He has no history of trauma to his neck. Surgical history is negative, and the patient does not take any medications. The mother tells you that thyroid problems run in the family. The patient has not been ill recently. Upon exam you feel a nontender, firm nodule on the right side of his thyroid with associated cervical lymphadenopathy. His serum TSH level is within the reference range. Radionuclide thyroid scanning demonstrates a "cold" nodule in the right side of the thyroid. What is the most appropriate next step in the work up of this patient? A MRI of the anterior pituitary B CT of the thyroid C MRI of the thyroid D Thyroid nodule fine needle aspiration E Emergent thyroidectomy - ✔✔Thyroid nodule fine needle aspiration The correct choice is D, thyroid nodule fine needle aspiration. With the advent of fine needle aspiration, it has become much easier, safer, and more reliable to obtain a specimen for biopsy. This patient has several characteristics that increase his risk of malignancy including his gender, young age, firmness of the nodule, and related lymphadenopathy. These, along with the ease of biopsy, suggest this path for diagnostic work up. Not enough information is known to warrant an emergent thyroidectomy, choice E. Choice A, MRI of the anterior pituitary, would be warranted if there was a suspicion of a pituitary cause of the thyroid nodules. Since the TSH is normal and the patient is not presenting with headaches or other pituitary related symptoms, this is not suggested. Choice B, CT of the thyroid, and choice C, MRI of the thyroid, would not provide any additional information after the thyroid scan. They may be helpful prior to any surgery if needed. Your patient has a history of primary hyperparathyroidism. Recently she has been hospitalized due to obstructing kidney stones. She has had several fractures including her hip, sacrum, and forearm in the past year, all on separate occasions. She is constantly complaining of a lack of energy. What is the recommended treatment for her symptomatic hyperparathyroidism? A surgical removal of the pituitary B high-dose calcium supplementation C parathyroidectomy D thyroidectomy E thiazide diuretics - ✔✔Parathyroidectomy The correct answer is (C). Primary hyperparathyroidism is most commonly secondary to a single parathyroid adenoma. The recommended treatment for symptomatic primary hyperparathyroidism is parathyroidectomy. High-dose calcium supplementation and thiazide diuretics, choices (B) and (E), can worsen the hypercalcemia associated with hyperparathyroidism. Neither surgical removal of the pituitary, choice (A), nor or a thyroidectomy, choice (D), is an indicated treatment for this condition. A 23-year-old patient with type 1 diabetes mellitus (DM) has been having difficulty sleeping at night. Usually around 3 am the patient will wake up feeling sweaty, nauseated, and tachycardic. He has recorded the following blood glucose levels: 10 PM- 90 mg/dL 3 AM- 40 mg/dL 7 AM- 200 mg/dL What advise is the best for this patient? A stop eating a bedtime snack B increase the evening regular dosage C decrease the evening Lente dosage D exercise before going to bed at night - ✔✔decrease the evening Lente dosage A 40-year-old patient presents to your walk-in clinic with symptoms of hyperhydrosis, oily skin, daytime sleepiness, and snoring. Upon exam, you note large fleshy heel pads and hands with sweaty palms. The patient also has coarse facial features. When asked, the patient isn't aware of any major changes in her face or body. She has not seen another health care provider in many years and has not kept up with any health care maintenance schedule. The patient lives with her ill mother and is not currently employed. Which of the following screening tests would best aid in the diagnosis of this patient? A CT of the chest and abdomen B Thyroid scan C 24-hour urine for catecholamines D Serum calcitonin level E Serum IGF-I level - ✔✔The correct choice is E, serum IGF-I level. Age and gender matched levels of IGF-I are elevated in patients with acromegaly. IGF-I is the mediator of most of the effects of GH on the body, and lead to the proliferation of bone, cartilage, and soft tissue. Although GH levels may be elevated in patients with acromegaly, they are secreted in a pulsatile fashion and are not consistently elevated. Serum GH levels are not the best screening test for acromegaly. Choices A, a CT of the chest and abdomen, and B, a thyroid scan, are expensive imaging studies that are not usually used as screening tests. They also have no role in the routine workup of patients with suspected acromegaly. Choice C, 24-hour urine for catecholamines, is a test that can be used in the work up of patients with suspected pheochromocytoma. Choice D, serum calcitonin levels, are associated with medullary thyroid cancer and other thyroid disease. An 18-year-old woman comes in for evaluation of "losing weight without meaning to." She also feels weak and in "always in the bathroom." Her appetite is normal but she "can't get enough to drink." Examination shows that she has lost 17# since her last visit a year ago. She is 66" tall and now weighs 120#. She is mildly orthostatic, but no other abnormalities are noted. A random blood sugar done in the office is 260mg/dl. Which results are most likely on measurement of her lipoproteins at this time? A decreased high density lipoprotein level B extremely elevated triglycerides C markedly increased total cholesterol D mildly elevated low density lipoproteins E normal profile - ✔✔mildly elevated low density lipoproteins In persons with diabetes mellitus, type 1, low density lipoproteins, trigycerides (B), and total cholesterol (C) are likely to be slightly elevatated. High density lipoproteins (A) remain about the same as the patient's baseline. Once the glucose level is controlled, the lipid levels (E) on the profile typically return to normal. Your patient comes to the office for a follow up of her atrial fibrillation and hypertension. She has noted that she have been more tired than usual. Laboratory findings include a thyroid-stimulating hormone (TSH) < 0.05 mU/L. What medication is the most likely cause of her laboratory findings? A cardizem B amiodarone C warfarin D dotalol E labetalol - ✔✔Amiodarone The correct answer is (B). Amiodarone is an antiarrhythmic medication containing iodine that is commonly used in treatment of atrial fibrillation. The use of amiodarone can cause thyrotoxicosis by several mechanisms and may also cause hypothyroidism. In this case the patients suppressed TSH would suggest the presence of amiodarone induced thyrotoxicosis. A high T 3 and FT 4 would support your diagnosis. All the other choices used in the treatment of atrial fibrillation would not cause thyroid dysfunction. Following a total thyroidectomy for papillary carcinoma, a 72-year-old man develops a heart rate of 140 and a temperature of 104.8F. He vomits almost continuously and has severe diarrhea. He is disoriented and mildly combative. Electrocardiography demonstrates sinus tachycardia. What is the most likely diagnosis? A pulmonary embolism B pneumonia C sepsis D thyroid storm E wound infection - ✔✔thyroid storm Although rare, thyroid storm or crisis can occur following thyroid surgery, administration of radioactive iodine, or a stressful illness. It is characterized by extreme tachycardia, vomiting, diarrhea, dehydration, delirium, and high fever. Pulmonary embolism (A) may include tachycardia, along with chest pain and shortness of breath, but is unlikely to include GI symptoms. Pneumonia (B) and sepsis (C) are certainly possible, although the extreme nature of her findings more strongly suggest thyrotoxicosis. Wound infection (E) would more likely to present with localized tenderness and a less marked fever. A 31-year-old woman is being evaluated for irregular, infrequent menstrual periods. On further questioning, she complains of headaches, fatigue, and breast discharge. She takes ibuprofen only occasionally. Which of the following labs would most likely be elevated in this patient? A BUN and creatinine B luteinizing hormone (LH) and follicle-stimulating hormone (FSH) C oxytocin D prolactin E TSH - ✔✔prolactin This patient's symptoms are consistent with a pituitary adenoma. Prolactinomas account for about half of all functioning pituitary tumors and may secrete PRL, GH, and ACTH. Release of which of the following substances is triggered by pituitary growth hormone and promotes growth of other tissues in the body? A C-pepide B IL-I C IGF-I D Thyroxine E Catecholamines - ✔✔IGF-I The correct choice is C, IGF-I or insulin like growth factor I. This growth factor leads to increased DNA, RNA, and protein synthesis, which leads to overgrowth of bone, soft tissue, and cartilage. Choice A, c-peptide, is a part of the prohormone of insulin. Choice B, IL-I or interleukin I, is an important cytokine that promotes cell activation. Choice D, thyroxine, potentiates the actions of growth hormone on tissues. Which of the following is appropriate in the pharmacologic management of patients with hypoparathyroid tetany? A Aggressive IV hydration B Cinacalcet hydrochloride PO C Calcium gluconate IV D Pamidronate IV E Calcitonin IV - ✔✔Calcium Gluconate IV The correct choice is C, calcium gluconate IV. In severe hypocalcemia, replacement calcium must be started promptly, as well as airway maintenance and magnesium and vitamin D replacement, as necessary. Choices A, aggressive hydration, B, cinacalcet hydrochloride, D, pamidromate, and E, calcitonin, are all possible treatment options for patients with hypercalcemia. A patient presents with polydipsia and polyuria. Diabetes mellitus is ruled out with a normal plasma glucose and hemoglobin A1c. You are concerned that he may have hypothalamic diabetes insipidus. If you are correct, what treatment would you recommend to this patient? A Lithium B Indomethacin C Metformin D Desmopressin E Fluid restriction - ✔✔Desmopressin The correct choice is D, desmopression. Patients with hypothalamic diabetes insipidus can't secrete vasopression (or antidiuretic hormone), since the vasopressin producing neurons are dead. Vasopressin analog desmopressin is available in tablets, nasal solution, and parenteral solution for patients with this disorder. Choice A, lithium, can cause nephrotoxicity, and can be a cause of acquired nephrogenic diabetes insipidus. Choice B, indomethacin, is an anti-inflammatory medication used to treat conditions such as gout. Choice C, metformin, is an oral diabetic medication that acts by suppressing hepatic glucose production. Patients must drink sufficient fluids to maintain serum sodium levels since without ADH, they can't conserve water. Therefore, choice E, fluid restriction, is not correct. Which of the following sets of lab values is most consistent with the diagnosis of Hashimoto's thyroiditis? A High serum TSH, low serum total T4, and high thyroidal peroxidase antibodies B Low serum TRH, low serum TSH, and low serum free T3 levels C Normal TSH, normal serum total T4, and normal radioactive iodine uptake D Low serum TSH, high serum total T4, and high thyroid stimulating antibodies E High serum TSH, high radioactive iodine uptake, and high serum free T3 - ✔✔High serum TSH, low serum total T4, and high thyroidal peroxidase antibodies The correct choice is A, high serum TSH, low serum total T 4 , and high thyroidal peroxidase antibodies. Hashimoto's thyroiditis is the most common cause of primary hypothyroidism and is autoimmune in nature. The serum thyroid hormone levels are low, secondary to the destruction occurring in the thyroid gland. The negative feedback loop causes the pituitary to respond by increasing production and secretion of TSH. Thyroidal peroxidase, thyroglobulin, and TSH receptor blocking autoantibodies can be found in these patients. Choice B, low serum TRH, low serum TSH, and low serum free T 3 levels, is seen in patients with secondary hypothyroidism relating to pathology in the hypothalamus. Choice C, normal TSH, normal serum total T 4 , and normal radioactive iodine uptake, is seen in patients who are euthyroid. Choice D, low serum TSH, high serum total T 4 , and high thyroid stimulating antibodies, are findings in patients with primary hyperthyroidism (e.g. Graves' disease). Choice E, high serum TSH, high radioactive iodine uptake, and high serum free T 3 can be seen in patients with secondary hyperthyroidism, as a result of anterior pituitary pathology. Which of the following is the most common cause of hypoparathyroidism? A Familial hypoparathyroidism B Idiopathic hypoparathyroidism C Severe magnesium depletion D Surgical removal of the parathyroid E Iron deposition in the parathyroid - ✔✔Surgical removal of the parathyroid Choice D, surgical removal of the parathyroid glands, is the correct answer. Surgery for head and neck cancer, thyroidectomy, and parathyroidectomy are the most common causes of hypoparathyroidism. Choices A, B, C, and E are all causes of hypoparathyroidism that occur more infrequently. A patient is being treated for hypothyroidism. His condition has been stable for the past year. What blood test should be ordered and monitored yearly in this patient? A Total T4 B T3 resin uptake C Thyroid releasing hormone D Thyroid stimulating hormone E Free T3 - ✔✔Thyroid stimulating hormone The correct choice is D, thyroid stimulating hormone. This test will help to monitor patient adherence with thyroid hormone supplementation, as well as to fine tune the dose so that the TSH remains within the reference range. Choices A, B, and E can be used in the work up of patients for primary hypothyroidism, but alone each test is not helpful to monitor chronic disease in patients. Choice C, serum thyroid releasing hormone, is used more commonly when investigating secondary hypothyroidism. A new patient to the practice reports that his paternal grandfather had a tumor of the pituitary gland, his father had hyperparathyroidism, one uncle had a pancreatic tumor and another a thyroid cancer. His first cousin has "some kind of facial tumors" and another relative had treatment for "producing too much stomach acid." Given this family history, he should be screened for which of the following? A Carney complex B Cowden disease C McCune-Albright syndrome D MEN1 E Sipple syndrome - ✔✔MEN1 This family history strongly suggests Multiple Endocrine Neoplasia 1, which are inherited in an autosomal dominant manner and involve mutations on the long arm of chromosome 11 (11a13). Carney complex (A) is another syndrome of multiple endocrine neoplasia (MEN) with tumors of the adrenal cortex, pituitary gland, thyroid, and gonads and with hyperpigmentation and cardiac myxomas. Cowden disease (B) is also a syndrome of MEN including thyroid abnormalities, breast cancer and hamartomas. Another MEN, McCune-Albright syndrome (C) is associated with precocious puberty, Cushing syndrome, hyperthyroidism, and acromegaly. Sipple syndrome (E), also known as MEN2a. may develop medullary thyroid carcinoma, pheochromocytomas, or Hirschsprung disease. An 88-year-old female patient has been advised by her primary care physican that she needs a computed tomography (CT) scan of her abdomen and pelvis due to persistent abdominal pain, bloating, and weight loss. She was told that she needs to hold one of her medications the day of the procedure and that she may resume the medication 48 hours later. She can't remember which medication she should discontinue. Which medication listed below should she discontinue temporarily as specified above due to the diagnostic test ordered? A glyburide B glipizide C pioglytizone D metformin E acarbose - ✔✔Metformin The correct answer is (D). A CT of the abdomen and pelvis requires p.o. and IV iodinated contrast unless ordered specifically without IV contrast. There is an increased risk of acute renal failure with IV iodinated contrast. The risk to the patient may increase with metformin and therefore should ideally be held prior to and for 48 hours after any radiocontrast IV study to avoid the added possibility of lactic acidosis. The other treatments for non-insulin-dependent diabetes mellitus (NIDDM) do not require discontinuation with IV contrast studies for these time periods. However, the am dose of a sulfonylurea (glyburide or glipizide) may be held until after the study that day when the patient resumes eating to avoid hypoglycemia in some patients. What is the most sensitive test available for the screening and detection of early thyroid dysfunction? A Radioactive iodine uptake B Serum T3 resin uptake C Serum total T4 level D Serum TSH level E Thyroid scan - ✔✔Serum TSH level The correct choice is D, serum TSH level. Very small changes in serum TSH level can provide clues that there are changes in the functioning of the hypothalamic-anterior pituitary-thyroid axis. The test is easier and less expensive than any thyroid imaging tests. All of the other choices can be used in the work up of patients for thyroid dysfunction, but they are less sensitive, and many are more expensive and more invasive. A patient is admitted to the hospital for an acute adrenal crisis. He has a history of chronic adrenal insufficiency and was admitted with severe weakness, nausea and vomiting while fighting a pulmonary infection. Which of the following suggested plans might this patient have forgotten or been unable to do? A Restrict fluid intake during times of metabolic stress B Increase the daily dose of hydrocortisone during times of metabolic stress C Hold the daily dose of hydrocortisone during times of metabolic stress D Add levothyroxine to the daily dose of hydrocortisone during times of metabolic stress E Increase the daily ingestion of proteins during times of metabolic stress - ✔✔Increase the daily dose of hydrocortisone during times of metabolic stress The correct choice is B, increase the daily dose of hydrocortisone during times of metabolic stress. The cortisol dose should be increased to between 60 and 80 mg/day, to mimic the normal physiologic response of the body. Increased mineralocorticoid therapy is generally not required. Choice A, restrict fluid, would aggravate the potential for the development of dehydration in this patient. Choice C would lead to further cortisol depletion. Choices D and E would not benefit this patient. You are evaluating an 80-year-old female for the first time. She has a history of mild Alzheimer's disease, for which she takes Aricept. She states that she feels fine but her daughter feels she is depressed and has been complaining of not feeling well. Her daughter admits that the patient has a history of primary hyperparathyroidism. What laboratory results would be most consistent with her diagnosis of hyperparathyroidism? A high serum calcium B low intact PTH C low cortisol D low urine calcium E high cortisol - ✔✔high serum calcium The correct answer is (A). The hallmark of primary hyperparathyroidism is a high serum calcium and high intact PTH. A low intact PTH is consistent with hypoparathyroidism. The urine serum calcium is usually high in primary hyperparathyroidism. Cortisol is related to endocrine conditions affecting the adrenal cortex. A 38-year-old man presents to the emergency department experiencing a severe headache and heart palpitations. He appears to be anxious and perspiring heavily. On exam, he is found to be tachycardic and his blood pressure is 158/102 mm Hg. His urine catecholamines are increased. If imaging were performed, what is the most likely location where a lesion would be found? A pituitary gland B liver C adrenal gland D testicle E kidney - ✔✔Adrenal gland Pheochromocytomas produce, store, and secrete catecholamines. They are usually derived from the adrenal medulla, although they may be found in other locations. A 30-year-old patient presents 2 months postthyroidectomy. The patient has had symptoms of increased irritability, muscle spasms, and hair loss for the past month. On physical examination, a positive Chovstek sign is noted. Which of the following is the most likely diagnosis? A hypothyroidism B hypopituitarism C hypoparathyroidism D hypogonadism - ✔✔hypoparathyroidism Hypoparathyroidism commonly presents following thyroidectomy surgery. This patient has classic signs and symptoms of a low calcium level and hypoparathyroidism. Chovestek sign is a physical exam finding that is positive after tapping in front of the ear in the facial nerve region. When doing this, the muscle contracts. When the calcium level is low, this occurs. Hypothyroidism can occur following a thyroidectomy but the symptoms are not the same. A young child and his parents have been adhering to the treatment plan for type 1 diabetes, as discussed with their health care provider. It includes a change in diet, as well as blood glucose and ketone monitoring. They noticed that the amount of insulin needed decreased after the first two weeks. What is this time period commonly called? A Postprandial control phase B Glucose tolerance time C Pre-diabetic period D Mature onset diabetes of youth E Honeymoon phase - ✔✔honeymoon phase The correct choice is E, honeymoon phase. During this time, some pancreatic beta cell function may recover, although within eight weeks to two years most patients will show absent or negligible pancreatic beta cell function. Choice A, postprandial control phase, choice B, glucose tolerance time, and choice C, pre-diabetic period, are not true time periods. Choice D, mature onset diabetes of youth, is a subgroup of autosomal dominant inherited disorders, characterized by diabetes in non-obese older children that are not ketosis prone and generally do not need insulin therapy to control their disease. This type of diabetes accounts for up to 5% of diabetes in North America and Europe. A 42-year-old woman has experienced recent weight gain, heavy periods, fatigue, cold intolerance, and constipation. She has a rough voice, and her rate of speech is slow. Physical exam is significant for an enlarged thyroid, slow reflexes, and the presence of brittle and coarse hair. She denies any history of bipolar disease or treatment with lithium. Laboratory tests show an elevated TSH and low free T 4 . What is the most appropriate treatment for this patient? A propylthiouracil (PTU) B levothyroxine C surgical resection D radioiodide ablation - ✔✔levothyroxine This patient's signs and symptoms are consistent with hypothyroidism. Treatment of choice is levothyroxine, which is partially converted in the body to T 3 . Significant increases are seen within 1 to 2 weeks, with maximum levels reached in 3 to 4 weeks. A 30-year-old woman presents to the office with polyuria, fatigue, and a chronic white vaginal discharge with vaginal pruritis. She has been having the discharge off and on for the past 6 months with recurrent treatment failures. Which of the following is the most likely diagnosis? A type 2 diabetes mellitus B hyperthyroidism C hypothyroidism D diabetes insipidus - ✔✔Type 2 DM Polyuria, polydipsia, and fatigue are all findings that can be consistent with both type 1 and type 2 diabetes. Any woman who presents with a chronic vaginal discharge or chronic vaginal pruritis should be screened for type 2 diabetes. Your patient states she has been gaining weight for no apparent reason over the past year and is concerned that she might have hypothyroidism. What other historical information would support a diagnosis of hypothyroidism? A anxiety B diarrhea C depression D palpitations E heat intolerance - ✔✔depression The correct answer is (C). Depression is a common presenting symptom of hypothyroidism. Weight gain can occur with hypothyroidism. Other symptoms may be weakness, fatigue, and menorrhagia. Hoarseness may also be a presenting symptom. The other choices are common symptoms of hyperthyroidism. A 30-year-old man is brought to the emergency department by his wife for abdominal pain, nausea, vomiting, and diarrhea. She says he has been getting "worse and worse" for at least the past two months. He is "too tired" and his "muscles hurt too much" to play golf, formerly their favorite leisure activity. He has been depressed and reticent, instead of his usual talkative self. He won't eat much of anything, even when she cooks his favorite meals and she is sure he has lost considerable weight because his clothes "hang off him." He has refused medical evaluation until today, when the abdominal pain of approximately a week increased and he began having the vomiting and diarrhea. Initial impression is that the man is quite tanned, although it is the middle of winter. Closer examination reveals dark pigmentation in his skin folds and on the buccal mucosa. This presentation most strongly suggests which of the following? A adrenocortical insufficiency B diabetic ketoacidosis C hypercortisolism D hyperglycemic hyperosmolar state E hypothyroidism - ✔✔adrenocortical insufficiency This is a fairly classic presentation of adrenocortical insuffiency (Addison's disease). Diabetes mellitus, type 1, that has led to ketoacidosis (B) could also present with weight loss, nausea, and vomiting; but is also accompanied by hyperphagia and polydipsia, and does not have the hyperpigmentation associated with Addison's disease. Patients with hypercortisolism (Cushing Syndrome) (C) present with central obesity, hirsutism, thin skin, poor wound healing, and a host of other problems including emotional lability. Those with hyperglycemic hyperosmolar state (D) are typically older, have a high body mass index, and present with lethargy, confusion, and dehydration. Patients with hypothyroidism (E) usually have weight gain and constipation along with lethargy, fatigue, and weakness. A patient describes an insidious onset of vague gastrointestinal symptoms including nausea, vomiting, and abdominal pain. She has been losing weight over the last few weeks as well. Past medical history reveals a new diagnosis of anemia. The patient is not currently taking any medications. Physical exam findings include hypotension and dark freckles with dark, bluish black pigmentation of the mucosal membranes. Serum sodium is decreased, while the potassium and plasma ACTH levels are elevated. What is the most likely diagnosis for this patient? A Acute abdomen B Cushing's syndrome C Primary adrenal insufficiency D Disseminated intravascular coagulation E Diabetic ketoacidosis - ✔✔Primary adrenal insufficiency The correct choice is C, primary adrenal insufficiency. This disorder presents with symptoms resulting from progressive destruction of the adrenal glands and resultant decrease in aldosterone and cortisol secretion. The presentation can range from subtle to fulminant adrenal crisis. Common clinical findings include hyperpigmentation, weakness, anorexia, nausea, vomiting, diarrhea, and hypotension. Some patients with adrenal insufficiency may initially be treated for an acute abdomen, choice A. In this patient, ACTH levels are known to be elevated, pointing the cause to the pituitary-adrenal axis. Choice B, Cushing's syndrome, presents with signs and symptoms related to an excess in plasma cortisol, such as truncal obesity, hyperglycemia, hypertension, skin changes, and weight gain. Choice D, disseminated intravascular coagulation, is a coagulation disorder presenting with bleeding and thrombosis. Choice E, diabetic ketoacidosis, is an acute complication seen in patients with type 1 diabetes mellitus. A 45-year-old woman comes to the office for evaluation of "yeast infection again." Review of the chart shows that she has had six episodes of vaginal candidiasis in the past 18 months. She and her husband have been mutually monogamous during their 23-year marriage; he had a vasectomy following the birth of their second child. Her two children weighed 10# 2 oz. and 10# 4 oz. at delivery. Her last menstrual period occurred one week ago and was slightly heavier than normal, but her preceding two periods were scanty and "off schedule." Her medications include a thiazide diuretic for mild hypertension and a senior multivitamin. She is 62" tall and weighs 198#. Assuming her examination demonstrates candidiasis, this woman needs most urgently to be screened for which of the following? A diabetes mellitus B hyperlipidemia C hypothyroidism D perimenopause E polycystic ovarian syndrome - ✔✔DM Diabetes causes recurrent vaginal candidiasis in women with uncontrolled glucose. Type 2 diabetes is further suggested by her obesity and history of macrosomia in offspring. Furthermore, thiazide diuretics may increase glucose levels. She needs also to be screened for hyperlipidemia (B), given her weight and probable diabetes, but that is not as urgent. She may be hypothyroid (C), although the clinical picture more strongly suggests diabetes; hypothyroidism is also more likely to cause menorrhagia than scanty periods. She may also be perimenopausal (D), given irregular menses. Polycystic ovarian syndrome (E) is unlikely given no history of infertility. A female patient presents with a history of hypertension and low plasma HDL. She is asking you if she has metabolic syndrome. She does not have diabetes and she is not obese. Which of the following NCEP ATP III criteria would be needed to confirm that diagnosis? A LDL > 70 mg/dL B LDL > 90 mg/dL C Triglycerides > 100 mg/dL D Triglycerides ≥ 150 mg/dL E Triglycerides > 300 mg/dL - ✔✔Triglycerides ≥ 150 mg/dL The correct choice is D, triglycerides ≥ 150 mg/dL. The NCEP ATP III criteria for metabolic syndrome include three or more of the following: Central obesity with waist circumference > 102 cm in men and > 88 cm in women Hypertriglyceridemia with serum triglycerides ≥ 150 mg/dL, or the patient is taking medication for hypertriglyceridemia Low HDL level < 40 mg/dL in men and < 50 mg/dL in women, or the patient is taking medication for low HDL Hypertension with blood pressure ≥ 130 mm systolic or ≥ 85 mm diastolic, or the patient is taking medication for high blood pressure Fasting plasma glucose ≥ 100 mg/dL, or a positive diagnosis for diabetes mellitus, or the patient is taking medication for hyperglycemia You are evaluating a 69-year-old female who complains of an intermittent sensation of hot flashes, flushing of her face/chest, and pruritus after starting a new medication for her cholesterol. Which of the following medications is the most likely cause of her symptoms? A niacin B lovastatin C gemfibrozil D ezetimibe E fenofibrate - ✔✔Niacin The correct answer is (A). Niacin has a characteristic side effect of hot flashes, flushing, and pruritus. These symptoms can be reduced by addition of ASA or a nonsteroidal anti-inflammatory drug (NSAID) if there are no contraindications. The other choices are unlikely to cause this combination of symptoms. A 45-year-old patient came in to see his health care provider today, to discuss the results of his last annual assessment. He was told that he had developed type 2 diabetes mellitus. One of the recommendations from the physician assistant included a visit to an ophthalmologist. The physician assistant was concerned after seeing new capillaries, macular edema, and fibrous tissue within the retina during his funduscopic exam. What type of ocular complication does this patient most likely have at this time? A Background retinopathy B Closed angle glaucoma C Macular degeneration D Diabetic cataracts E Proliferative retinopathy - ✔✔Proliferative retinopathy The correct choice is E, proliferative retinopathy. The distinguishing factor in the patient's presentation, which signals this disorder, is the development of newly formed vessels. Proliferative retinopathy is the leading cause of blindness in the United States. Up to 20% of patients with type 2 diabetes have retinopathy at the time of diagnosis. Choice A, background retinopathy, or simple retinopathy includes retinal microaneurysms, hemorrhages, exudates, and edema, without new vessel formation. Choice B, closed angle glaucoma, is relatively uncommon in patients with diabetes, except after cataract extraction. Choice C, macular degeneration, is not associated with diabetes mellitus specifically. Choice D, diabetic cataracts, tends to occur in patients with diabetes earlier than the general population, and may correlate with the severity of the disease. A 30-year-old healthy female's labs return showing an HDL of 28 mg/dl, LDL of 132 mg/dl, and total cholesterol of 185mg/dl. She is concerned due to a family history of coronary artery disease (CAD) on her father's side in his 60s. She denies tobacco use. Her blood pressure is 108/50, P-64. She requests advice on what she can due to increase her HDL. What do you advise her? A atorvastatin B cholestyramine C ezetimibe D gemfibrozil E exercise - ✔✔exercise The correct answer is (E). This patient is at very low risk of CAD based on the 10-year Framingham projections. Based on her < 1%, 10-year risk drug therapy is not indicated. Exercise has been shown to increase HDL. HDL is lower in patients who have a sedentary lifestyle or are obese. Her LDL may also be reduced with exercise, weight loss, and dietary modifications. A 14-year-old boy presents to the emergency department with his parents. He has a history of type 1 diabetes, and has had bronchitis for the last few days. He is now presenting with difficulty breathing, worsening fatigue, polydipsia, and polyuria. His last fingerstick glucose at home this morning was 350 mg/dL. Which of the following patterns of breathing are characteristic of this complication of diabetes? A Cheyne stokes respiration B Bradypnea C Biot breathing D Kussmaul breathing E Painful respiration - ✔✔kussmaul breathing The correct choice is D, Kussmaul breathing, which is deep regular breathing or hyperpnea. It can be seen as a compensatory action of metabolic acidosis and hypoxia. Choice A, Cheyne-Stokes respiration, is a waxing and waning pattern of rate and volume that includes periods of apnea. This can be seen in patients at high altitudes, and with severe left sided heart failure or neurologic disease. Choice B, bradypnea, is noted with a slower than usual respiratory rate and can be seen with use of CNS depressant drugs, uremia, or structural intracranial lesion. Choice C, Biot breathing, is an uncommon variant of Cheyne-Stokes respiration, with periods of apnea alternating with a series of equal breaths that end abruptly. It can be seen in patients with meningitis. Choice E, painful respiration, is relatively normal in pattern, but interrupted by pain during breathing from such disorders as pleurisy, fractured ribs, or subphrenic inflammation. 42-year-old female complains of weight gain (especially in her abdomen) over the past 8 months. She also has noted that her skin bruises easily. Her husband has noted she seems to be very moody lately and she is worried about their relationship. Furthermore, her hair seems to be getting thinner and she is now getting acne like she had in her teenage years. She wonders if this is due to menopause since her periods have stopped suddenly about a year ago. On physical examination her BP = 170/50, P = 82, T = 98.2˚F. You note the following findings on examination (see picture). What diagnostic test is indicated initially to confirm your suspected diagnosis? A cosyntropin stimulation test B MRI pituitary C dexamethasone suppression test D 24-hour urine for protein E serum protein electrophoresis - ✔✔dexamethasone suppression test The correct answer is (C). The patient's symptoms are consistent with a diagnosis of Cushing's syndrome (or disease). Her physical examination findings of hypertension and abdominal obesity with the classic purple striae also support the diagnosis. The initial diagnostic test of choice would be the dexamethasone suppression test. If the test is positive, further confirmatory testing is done which would also help to identify the cause. An MRI of the pituitary is appropriate if further testing suggests the possibility of a pituitary adenoma as the cause of the Cushing's syndrome, but is not used as an initial diagnostic test for Cushing's disease. A cosyntropin stimulation test, choice (A), is indicated for the diagnosis of Addison's disease. A 40-year-old female presents to your office with symptoms of weight gain, hirsuitism, and easy bruising. Past medical and surgical history is noncontributory. She drinks one glass of wine on weekends and does not smoke cigarettes. She takes one multivitamin daily. Upon physical exam, you note facial fullness, central obesity, and thin skin. Which of the following is a valuable biochemical screening test for this patient that will aide in the diagnosis? A Dexamethasone suppression test B Radioactive iodine uptake C Glucose tolerance test D Cosyntropin stimulating test E Plasma fractionated free metanephrines - ✔✔Dexamethasone suppression test The correct choice is A, dexamethasone suppression test. This patient is presenting with classic signs and symptoms of Cushing's syndrome. The dexamethasone suppression test is a simple test of the hypothalamic-pituitary-adrenal axis, and requires ingestion of oral dexamethasone at nighttime and a blood test in the morning hour, to measure the amount of plasma cortisol. Most patients with Cushing's syndrome demonstrate a lack of normal axis suppression and present with a morning plasma cortisol level >5 mcg/dL. Choice B, radioactive iodine uptake, is used in patients with suspected thyroid disorders. Choice C, glucose tolerance test, is used in patients with suspected diabetes mellitus and in prenatal testing, to investigate gestational diabetes. Choice D, cosyntropin stimulating test, is used to investigate possible adrenal insufficiency. Choice E, plasma fractionated free metanephrines, is used in the diagnostic workup of pheochromocytoma. Which of the following drugs can cause syndrome of inappropriate antidiuretic hormone (SIADH)? A carbamazepine B glyburide C lithium carbonate D metoprolol - ✔✔carbamazepine Many medications can enhance the release or potentiate the effects of ADH. Carbamazepine may increase ADH release. A 28-year-old woman presents with nervousness and palpitations associated with heat intolerance. On examination, there is no evidence of thyromegaly, but there is a palpable nodule that is "hot" on a thyroid scan. The TSH was low and T3 and T4 were both elevated. Which of the following is the recommended treatment for this patient? A Propylthiouracil (PTU) B Thyroid lobectomy C Total thyroidectomy D Radioiodine ablation - ✔✔thyroid lobectomy In Graves' disease, the thyroid is diffusely enlarged in contrast to a toxic adenoma in which the thyroid is normal sized but with a palpable nodule. Surgery is the treatment of choice for a toxic adenoma. Surgical treatment of a toxic adenoma is a thyroid lobectomy and isthmusectomy. A subtotal or total thyroidectomy is indicated for toxic multinodular goiters or Plummer disease. Thionamides and radioiodine ablation are not effective therapies for toxic adenomas. (Coe, 2006, pp. 404-406) Coe NPW. Surgical endocrinology: thyroid gland. In a patient who does not have thyroid disease, an elevated serum thyroid stimulating hormone (TSH) may be found under which of the following conditions? A acute corticosteroid administration B acute psychiatric admission C development of an hCG-secreting tumor D pregnancy E use of amphetamines - ✔✔acute psychiatric admission About 15% of patients who are admitted for an acute psychiatric illness will have an elevated TSH in the absence of thyroid disease. Acute corticosteroid administration (A), hCG-secreting tumors (C), pregnancy (D), and use of amphetamines (E) are all associated with low TSH levels. Your patient is taking atorvastatin 40 mg daily for her history of hyperlipidemia. Based on the potential side effects of this medication what labs are indicated for periodic monitoring? A HGB/HCT B AST/ALT C WBC count D TSH/T4 E B12 - ✔✔AST/ALT The correct answer is (B). Atorvastatin is an HMG-CoA reductase inhibitor, which has a potential to cause liver injury. It is recommended that liver enzymes are monitored regularly due to the potential for liver injury. The remaining choices are incorrect because statins are not known to cause changes in these laboratory values and monitoring based on potential adverse reactions to atorvastatin is not recommended. A patient with long-standing, untreated acromegaly is seen in your office with symptoms of severe headaches. After completing a thorough history and physical exam, you order a set of x-rays including a skull series. Which of the following findings would you expect in this patient? A Punched out lesions B Basilar skull fracture C Metastatic bone lesions D Enlarged sella tursica E Thinning of the skull - ✔✔Enlarged Sella tursica The correct choice is D, enlarged sella tursica. This finding is seen in 90% of patients with acromegaly. Other findings on skull radiographs include thickened calvarium (upper portion of the skull), enlarged mandible, and sinuses. Bony growth is a hallmark of the disease. The pituitary adenoma, which typically causes the disease, can be found in the sella tursica. This disorder doesn't typically metastasize, and is not associated with metastatic bone cancer, as noted in choice C. Choice A, punched out lesions, are commonly associated with Paget's disease. There is no history of head trauma, as would be the case in choice B, basilar skull fracture. As noted earlier, the skull may be thickened. Therefore, choice E, thinning of the skull, would not fit this patient's presentation. Which of the following is the most common cause of primary adrenal insufficiency in the United States? A Tuberculosis B Adrenal hemorrhage C Lymphoma D Autoimmune destruction E Metastatic carcinoma - ✔✔Autoimmune destruction The correct choice is D, autoimmune destruction. This is responsible for 80% of cases of primary adrenal insufficiency in the United States. All of the other choices can cause adrenal insufficiency, but they are less common. Tuberculosis, choice A, is a common cause of adrenal insufficiency in other areas of the world, where the infection is more common. Bilateral adrenal hemorrhage, choice B, can occur as a complication of sepsis, heparin use, anti-phospholipid syndrome, and after major trauma or surgery. Lymphoma, choice C, and metastatic carcinoma, choice E, are rare causes of adrenal insufficiency. Your patient is a 77-year-old male with a history of hypertension. For about the past 50 years has smoked a pipe daily. He feels great but admits that his cholesterol was elevated for the past 5 years, and has declined treatment. His best friend died of an myocardial infarction last week and the patient now agrees to treatment for his hyperlipidemia. His LDL is 285 mg/dl and HDL is 30 mg/dl. You decide to put him on simvastatin 80 mg QD. Prior to initiation, you advise the patient to notify you about which of the following potential side effects of this medication? A cough B double vision C myalgias D elevated blood pressure E restlessness - ✔✔myalgias The correct answer is (C). Myalgias are common side effects of statins, which may result in a patient discontinuing the medication. If the patient develops significant myalgias a CPK may be ordered to rule out myositis and if elevated the statin may need to be discontinued. Elevated liver enzymes may occur, which may result in discontinuation of the medication. The other options are unlikely side effects of statins. Patients diagnosed with type 2 diabetes are encouraged to maintain their plasma glucose, to prevent or slow the initiation of chronic complications. What is the maximum level that is within ADA guidelines for a one to two hour postprandial plasma glucose in these patients? A 70 mg/dL B 100 mg/dL C 120 mg/dL D 180 mg/dL E 220 mg/dL - ✔✔180 mg/dL The correct choice is D, 180 mg/dL. Patients are encouraged to adhere to lifestyle and medication treatment plans in order to help achieve this goal. Other ADA guidelines include maintaining the hemoglobin A1c < 7% or as close to normal (<6%) as possible, blood pressure < 130/80, and preprandial glucose between 90 and 130 mg/dL. Your patient is asked to see you in followup for his fasting labs. His total cholesterol = 230 mg/dl, triglycerides = 1200 mg/dl, unable to calculate LDL. Your patient should be advised that due to these findings he is at risk for which of the following? A diabetes mellitus B pancreatitis C gout D diabetes insipidus E hypertension - ✔✔pancreatitis B The correct answer is (B). Very elevated triglycerides, especially over 1000 mg/dl, increase the patient's risk of acute pancreatitis. This patient requires prompt treatment. Hypertriglyceridemia may be a component of metabolic syndrome but does not directly cause diabetes mellitus or hypertension. Hypertriglyceridemia does not increase the risk of gout and diabetes insipidus. A 25-year-old woman is seen today in your office for vague abdominal pain, nausea, anorexia, weight loss, anxiety, and dizziness. Her past medical history is significant for type 1 diabetes mellitus, and her family history is significant for hypothyroidism in several family members. A review of systems reveal a history of amenorrhea. Upon exam, you note hyperpigmentation of her skin and areas of vitiligo, but no mucocutaneous candidiasis. You are not surprised to find that her serum ACTH level is elevated and her serum cotisol is low. Which of the following syndromes should be investigated in this patient? A Type 1 polyglandular autoimmune syndrome type 1 B Type 2 polyglandular autoimmune syndrome type 2 C Multiple endocrine neoplasia type 2A D Multiple endocrine neoplasia type 1 E Metabolic syndrome - ✔✔Type 2 polyglandular autoimmune syndrome type 2 The correct choice is B, type 2 polyglandular autoimmune syndrome. This patient is presenting with signs and symptoms of adrenal insufficiency including abdominal pain, nausea, anorexia, vomiting, weight loss, anxiety, and hyperpigmentation. Type 2 polyglandular autoimmune syndrome presents most commonly in young women between 20 and 40 years old, with evidence of adrenal insufficiency, type 1 diabetes mellitus, and autoimmune thyroid disease. Because of the strong family history of thyroid disease, it would be prudent to conduct an investigation into this disorder, starting with a serum TSH level. Primary ovarian failure and vitiligo may be symptoms of the autoimmune polyglandular syndrome as well. Choice A, type 1 autoimmune polyglandular syndrome, presents more commonly in childhood with adrenal insufficiency, hypoparathyroidism, and mucocutaneous candidiasis. Choices C and D are inherited disorders, characterized by the development of several different types of endocrine organ neoplasias. Choice E, metabolic syndrome, includes a constellation of several metabolic disorders that increase the risk of cardiovascular disease and diabetes mellitus in the patient. A 43-year-old obese man presents for a health maintenance visit. On physical exam, it is noted that his waist circumference is 106 cm and blood pressure is 148/92 mm Hg. Which of the following fasting laboratory levels would suggest a diagnosis of metabolic syndrome (syndrome X) in this patient? A HDL of 45 mg/dL B LDL of 180 mg/dL C triglyceride of 190 mg/dL D glucose of 100 mg/dL - ✔✔triglyceride of 190 mg/dL Metabolic syndrome is found in approximately 25% of Americans. It is defined as three or more of the following findings: waist circumference of greater than 102 cm in men or greater than 88 cm in women; serum triglyceride level of at least 150 mg/dL, HDL level of less than 40 mg/dL in men or less than 50 mg/dL in women; blood pressure of at least 130/85 mm Hg; and serum glucose level of at least 110 mg/dL. A 10-year-old child is seen with his parents for a routine check up. During the review of symptoms, his parents mention that their son has been extremely thirsty and is going to the bathroom to urinate frequently. The patient agrees. The parents are concerned that their son has developed diabetes mellitus. The family history is negative for diabetes mellitus, but the mother has a history of familial hypothalamic diabetes insipidus. Screening blood work includes a CBC, hemoglobin A1c, and renal function tests, all of which are within the reference range. Which of the following serum analytes would you expect to be deficient? A Sodium B Glucose C Thyroxine D Prolactin E Vasopressin - ✔✔vasopressin The correct choice is E, vasopressin. The reader must first understand that the patient's symptoms are classic for diabetes insipidus, with the increased thirst, frequency, and polyuria. These symptoms are also seen in diabetes mellitus, but this would be less likely since the patient doesn't have a family history of diabetes mellitus, and his hemoglobin A1c is not elevated. Choice A, sodium, should be within range, as long as the boy is able to drink when thirsty; otherwise, he would become hypernatremic. Choice B, glucose, is incorrect. Although the signs and symptoms also fit the pattern of diabetes mellitus, the glucose would most likely be elevated in this disorder, and not low. Choice C, thyroxine, is under control of TSH from the anterior pituitary gland, and choice D, prolactin, is secreted from the anterior pituitary gland. Vasopression is secreted from the posterior pituitary gland. What is the definitive treatment of choice for elderly patients diagnosed with Graves' disease? A Beta blocking agents B Levothyroxine C Methimazole D Total thyroidectomy E Radioactive iodine - ✔✔Radioactive Iodine The correct choice is E, radioactive iodine. This is the treatment of choice in the elderly because it is efficient, easy to take, and inexpensive. Choice A, beta blocking agents, are useful in the treatment of symptoms of hyperthyroidism, such as palpitations, but they are not a definitive treatment for the disorder. Choice B, levothyroxine, is used for thyroid hormone supplementation in patients with hypothyroidism. Choice C, methimazole, is an anti-thyroid drug that has increased toxicity in the elderly and is more useful in younger patients with mild hyperthyroidism. Choice D, total thyroidectomy, has a limited role as a treatment for hyperthyroidism, and is associated with increased morbidity in the elderly. Consideration should be given to screening patients with type 1 diabetes mellitus should also be screened for which of the following: A sarcoidosis B Sheehan's syndrome C Sjögren's Syndrome D thyroid disease - ✔✔Sjögren's Syndrome Type 1 diabetes mellitus (T1DM) is an autoimmune disease. As such, patients have a significantly higher risk of other autoimmune diseases, including celiac and thyroid disease. Most recommendations include screening for both diseases in patients with T1DM. A 70-year-old woman who was found barely responsive at home by her daughter is brought to the emergency department. Evaluation reveals that she is in a hyperglycemic hyperosmolar state with a severe fluid deficit. Treatment is initiated with vigorous saline rehydration and a continuous infusion of insulin. At what point should her glucose be added to her treatment? A when her condition becomes stable B when her urine output reaches 50 mL/hour C when her blood glucose reaches 250 mg/dL D if she develops hypokalemia E if she begins to spill ketones in her urine - ✔✔when her blood glucose reaches 250 mg/dL In hyperglycemic hyperosmolar states, the serum glucose rapidly corrects with fluid administration alone. However, with vigorous rehydration, glucose may fall precipitously and lead to severe hypoglycemia. To avoid this, glucose should be added to water, half-normal, or normal saline as soon as the patient's blood glucose is less than or equal to 250mg/dL. She should continue to receive insulin IV until she is stabilized (A) when it can be switched to subcutaneous administration. The goal of fluid therapy in this patient is restoring her urine output to 50 mL per hour (B) or more. Because insulin drives potassium into the cells and can cause hypokalemia (D), potassium chloride should be given unless the patient has chronic kidney disease or oliguria. Persons in a hyperglycemic hyperosmolar state typically do not spill ketones (E) the way persons with diabetic ketoacidosis do. A 5-year-old child presents for her kindergarten checkup. The clinician notes that over the past couple of years, her height decreased from the 50th percentile to the 5th percentile. On examination, the clinician also notes truncal adiposity. Her CBC and lead levels were normal. Which of the following is the most likely diagnosis? A growth hormone deficiency B Cushing disease C congenital hypothyroidism D congenital adrenal hyperplasia - ✔✔GH deficiency Growth hormone (GH) deficiency is defined as a decreased growth velocity, delay in skeletal maturation, absence of other explanations for poor growth (lack of intake), and laboratory tests demonstrating decreased GH secretion. Etiology of GH deficiency can be congenital, genetic, acquired, or idiopathic, which is the most common. Infants usually have a normal birth weight and may have a slightly decreased length. In addition, most infants present with other endocrine deficiencies like hypoglycemia, hypothyroidism, and/or adrenal insufficiency. Children may present with truncal adiposity because growth hormone promotes lipolysis. Serum GH or intrinsic growth factor levels may or may not be decreased. In patients who do not have a demonstrated decrease in these hormones, a trial period with GH is indicated. These patients and positive GH-deficient patients receive a once-daily subcutaneous injection of recombinant human GH. Congenital hypothyroidism typically presents with short stature (typically noted after the 4-month newborn visit), delayed epiphyseal development, delayed closure of fontanelles, and retarded dental eruption in addition to other signs of hypothyroidism. Cushing disease typically presents with truncal adiposity with thin extremities, muscle wasting, decreased growth rate, and moon facies. Laboratory results show elevated adrenocorticosteroids both in urine and serum, hypokalemia, eosinopenia, and lymphocytopenia. Typically, in patients younger than the age of 12, Cushing disease is secondary to administration of ACTH or glucocorticoids. Congenital adrenal hyperplasia typically presents with pseudohermaphroditism in females or salt-losing crisis in males with or without isosexual precocity. There is an increased linear growth and advanced skeletal maturation. A patient was recently diagnosed with acromegaly. He was reading on the Internet that acromegaly is associated with diabetes mellitus. He is especially concerned, since his father was recently diagnosed with diabetes as well. How would you reply to the patient's following question: "What percentage of people with acromegaly develop diabetes mellitus?" A 10% B 25% C 50% D 65% E 80% - ✔✔25% The correct choice is B, 25%. Growth hormone is a counter-regulatory hormone of insulin, and therefore acts against insulin. This can lead to hyperglycemia, glucose intolerance, and diabetes mellitus in 25% of patients with acromegaly. A 42-year-old woman comes in with a "lump in her neck." When she was a teenager, she underwent radiation treatment for "some kind of tumor" in her neck. Ultrasound reveals a 1.5 cm lesion in the left lobe of the thyroid; biopsy confirms papillary carcinoma. Thorough evaluation reveals no evidence of metastasis. Which of the following is the initial treatment of choice for her? A chemotherapy B lobectomy with isthmectomy C radiation therapy D radioactive iodine therapy E total thyroidectomy - ✔✔Total thyroidectomy Total or near-total thyroidectomy is indicated for this woman. No chemotherapy (A) is available for thyroid cancer. Lobectomy with isthmectomy is reserved for papillary carcinoma that is less than 1 cm in size in persons with no history of radiation exposure and no evidence of metastasis. Radiation therapy (C) is used to treat bone metastasis and anaplastic carcinoma. Radioactive iodine therapy (D) may be used following thyroidectomy to ablate any remnant of the gland and to treat cancer that has metastasized or is otherwise high risk. Which of the following statements regarding diabetic medications is/are most correct? A Incretin-mimetics like exenatide commonly result in weight loss. B Thiazolidinediones (TZDs) should be held prior to and for 48 hours after administration of ionidated contrast material. C Sulfonylureas have the highest risk of hypoglycemia of all oral diabetic agents. D Sulfonylureas help preserve beta-cell function. E All of the above. - ✔✔all of the above Incretin-mimetics act upon the satiety center of the brain and as a result promote weight loss, averaging approximately six pounds. Metformin may cause fatal lactic acidosis when given to patients on concomitantly-administered iodinated contrast dye. Sulfanylureas, in part because of first-pass metabolism, have the highest risk of hypoglycemia of all the oral anti-diabetic agents. TZDs have been found to preserve beta-cell function more so than any other agent. A 50-year-old male is seen with a routine check-up. He is concerned about the possibility of developing diabetes mellitus. He has a negative family history of diabetes. He has no signs or symptoms of diabetes and he is not overweight. Without any risk factors for diabetes, what is the recommended screening protocol for this patient according to the American Diabetes Association (ADA)? A screen all men over 25 years of age every five years B screen all men over 35 years of age every two years C screen everyone over 45 years of age every three years D no screening is necessary without risk factors E no screening is necessary without a family history of diabetes - ✔✔Screen everyone over 45 yo every 3 years The correct choice is C, screen everyone older than 45 years of age every three years. In addition, the ADA recommends screening for younger people if they are overweight and have at least one additional risk factor, such as positive family history, hypertension, and/or vascular disease. The other choices are not recommended by the ADA for screening the general population for diabetes mellitus. A patient was recently diagnosed with type 1 diabetes mellitus. A treatment plan was initiated, with a combination regimen of insulin. Which of the following types of insulin works well with a rapidly acting insulin, such as insulin lispro, to provide 24-hour coverage for the patient? A NPH insulin B Regular insulin C Insulin aspart D Insulin glargine E Humalog 75/25 - ✔✔Insulin glargine The correct choice is D, insulin glargine. This is the only long acting insulin listed. The combination of a long acting insulin with a rapidly acting insulin provides physiologic insulin replacement to the patient. This regimen provides postprandial control after meals and basal coverage throughout the day and night. Choice A NPH insulin, can be used by itself in two or more injections throughout the day. Choice B, regular insulin, can be used instead of rapid acting insulin, and not in combination with it. Choice C, insulin aspart, is a type of rapidly acting insulin and would not be used in combination with another rapidly acting insulin. Choice E, Humalog 75/25, is a combination insulin preparation with 75% intermediate acting insulin and 25% insulin lispro. A 45-year-old woman presents with recent, unexplained weight loss, and lethargy. She has had several episodes of nausea and vomiting. She admits to craving salty foods. On physical examination, there is a hyperpigmentation to her skin and mucus membranes. Her blood pressure is 85/60 mm Hg. Her laboratory results show hyponatremia and hyperkalemia. Her serum ACTH level is elevated. Question What is the most likely site of the pathology? Answer Choices 1 Pituitary 2 Adrenal medulla 3 Pancreas 4 Adrenal cortex 5 Sympathetic ganglia - ✔✔Adrenal Cortex Explanation This patient has signs and symptoms consistent with Addison's disease. Addison's disease is primary adrenal insufficiency. The symptoms include weight loss, lethargy, nausea, vomiting, and salt craving. Due to the lack of mineralocorticoids, there will be hyponatremia and hyperkalemia. Addison's disease is primary adrenal insufficiency; therefore, the pathology is located in the adrenal cortex. The primary problem is not in the pituitary. There would be an ACTH deficiency, rather than an elevated ACTH, if the primary pathology were located in the pituitary. In this scenario, the pituitary is responding appropriately by increasing ACTH secretion, thus the elevated ACTH level. Addison's disease is also not due to pathology in the adrenal medulla, pancreas, or sympathetic ganglia. A 54-year-old man presents because he has very large urine output and is constantly thirsty. His urine output is many liters per day. He wakes up at night to urinate. His past medical history is remarkable for a 25-year history of a bipolar disorder; it is treated effectively with lithium. His lab results are as follows: TEST RESULTS REFERENCE RANGE BUN 17 mg/dL 10-20 mg/dL Calcium 9.9 mg/dL 8.5-10.5 mg/dL Potassium 4.2 mEq/L 3.5-5.0 mEq/L Sodium 149 mEq/L 135-145 mEq/L Glucose (fasting) 109 mg/dL 65-110 mg/dL The results of his urinalysis are as follows: TEST RESULTS REFERENCE RANGE Urine dipstick blood Negative Negative Urine dipstick glucose Negative Negative Urine dipstick ketones Negative Negative Urine dipstick protein Negative Negative 24 hour urine protein 124 mg/24 hr <150 mg/24 hr Urine osmolality 40 mOsm/kg 50-1400mOsm/kg Urine specific gravity 1.001 1.001-1.035 Urine pH 6.2 4.5-8.5 Question What structure is most involved in the pathophysiology of this condition? Answer Choices 1 Neurohypophysis 2 Adenohypophysis 3 Glomerulus 4 Loop of Henle 5 Collecting duct - ✔✔Collecting ducts Explanation Collecting dust is the correct response. A known side effect of lithium is nephrogenic diabetes insipidus. This side effect is experienced by a significant minority of the patients taking lithium. Nephrogenic diabetes insipidus results when the collecting duct of the kidney does not respond to the antidiuretic hormone (ADH). The posterior lobe of the pituitary is the neurohypophysis. The neurohypophysis secretes antidiuretic hormone (ADH) and oxytocin. The production of the posterior pituitary hormones actually occurs in the hypothalamus. The anterior lobe of the pituitary is the adenohypophysis. The anterior lobe of the pituitary secretes follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, growth hormone (GH), thyroid-stimulating hormone (TSH), and adrenocorticotropic hormone (ACTH) (and the corticotropin related peptides). The collecting duct is a portion of the nephron. It is also called the collecting tubules. Urine enters the collecting duct from the distal convoluted tubule. The collecting duct is responsive to ADH. The glomerulus is a specialized capillary tuft. The endothelium of the glomerulus is fenestrated. The glomerulus is surrounded by Bowman's capsule. A renal corpuscle consists of the glomerulus and Bowman's capsule. A renal corpuscle is sometimes called a Malpighian corpuscle. Renal corpuscles are seen in the kidney cortex. The loop of Henle is part of the nephron. It is shaped like a hairpin. The proximal convoluted tubule leads into the descending limb of the loop of Henle. The ascending limb of the loop of Henle goes to the distal convoluted tubule. A 70-year-old woman with long-standing type II diabetes mellitus presents with complaints of pain in the left ear with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal. Question What organism is most likely to grow from the purulent drainage? Answer Choices 1 Candida albicans 2 Haemophilus influenza 3 Moraxella catarrhalis 4 Pseudomonas aeruginosa 5 Streptococcus pneumoniae - ✔✔Pseudomonas Aeruginosa Explanation Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. The swelling and inflammation of the external auditory meatus strongly suggest this diagnosis. This infection usually occurs in older, poorly controlled diabetics, and it is almost always caused by P. aeruginosa. It can invade contiguous structures, including the facial nerve or temporal bone, and it can even progress to meningitis. S. pneumoniae, H. influenzae, and M. catarrhalis frequently cause otitis media, but not external otitis. Candida albicans almost never affects the external ear. Psammoma bodies are concentric calcified structures and are found in several tissue pathologies. In the image, psammoma bodies can be seen. Psammoma bodies are characteristic of which of the following? Answer Choices 1 Papillary carcinoma of the thyroid 2 Mucinous cyst adenocarcinoma of the ovaries 3 Medullary carcinoma of thyroid 4 Follicular adenoma 5 Pheochromocytoma - ✔✔Papillary carcinoma of the thyroid Explanation Single necrotic cells may form a nidus for deposition of calcium. Subsequently, the progressive acquisition of an outer layer of calcium may form a lamellated structure, which resembles grains of sand. This is called a psammoma body. Psammoma bodies are seen in some neoplastic conditions, such as papillary carcinoma of the thyroid, serous cyst adenocarcinoma of the ovary, adenocarcinoma of the endometrium, and meningioma. Rarely, it may be seen in adenocarcinoma of the lung. In the case of the ovary, the possible mode of formation is by neoplastic and histiocytic cellular degeneration. Psammoma bodies (blue arrow) - calcific concretions with well-defined concentric laminations A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and tremor in her hands. You note the presence of bulging eyes and suspect Graves' disease. What blood levels should be taken so that the disease can be confirmed? Answer Choices 1 Thyroid stimulating hormone 2 Thyroid peroxidase 3 Protein-bound iodine 4 Thyroglobulin 5 Thyrotropin-releasing hormone - ✔✔TSH Explanation Graves' disease is a type of hyperthyroidism caused by a generalized over-activity of the entire thyroid gland. The patient appears hot and flushed, and the thyroid gland enlarges in this condition. It is believed that Graves' disease is an autoimmune disorder. Antibodies are produced against certain proteins on the surface of thyroid cells, stimulating those cells to overproduce thyroid hormones. In this condition antibodies are produced against the thyrotropin receptor, thyroglobulin, thyroid peroxidase, and sodium-iodide symporter. The circulating autoantibodies continuously stimulate the thyroid gland via the thyrotropin receptor. Associated suppression of the pituitary thyrotropin level is due to increased production of thyroid hormones. The onset of the disease is gradual, and the symptoms may be mistaken for nervousness due to a stressful life situation. Weight loss occurs, and it is followed by other symptoms, such as trembling, muscle weakness of the upper arms and thighs, and insomnia. The pituitary gland releases Thyroid Stimulating Hormone (TSH) in response to insufficient levels of thyroid hormone. Communication between the pituitary gland and the thyroid gland through TSH levels controls the levels of thyroid hormone in the blood. If the levels of thyroid hormone are low, then the levels of TSH will rise. The measurement of TSH in the blood is taken as a measure of thyroid function. In Graves' disease, there is a suppressed level of thyrotropin along with elevated levels of free T4 or T3 hormone levels. The new generation (III generation) assay of TSH is very sensitive and has revolutionized diagnosis of Graves' disease by providing accurate measurements of very low TSH levels. Suppression of TSH is an early and highly sensitive marker of thyrotoxicosis. Estimation of thyroid peroxidase, protein-bound iodine, thyroglobulin, and thyrotropin-releasing hormone are not as reliable as TSH assay. A 21-year-old insulin-dependent diabetic college student is acutely agitated and is verbalizing expletives. Prior to admitting him to an acute psychiatry inpatient service and administering intra muscular chlorpromazine (Thorazine) or haloperidol (Haldol), for what should he be evaluated? Answer Choices 1 Hyponatremia 2 Hypokalemia 3 Hypocalcemia 4 Hypovolemia 5 Hypoglycemia 6 Hypomagnesemia 7 Hypothermia - ✔✔Hypoglycemia Explanation Hypoglycemia, reduced blood glucose level below the laboratory reference ranges, is most likely to present with a toxic-metabolic state emulating an acute agitation and/or an acute psychosis; this patient demonstrates these symptoms. Given the known history of diabetes, and even in the absence of a history of a insulin-dependent diabetes disorder, the health care provider should check the patient's blood glucose level; if found to be low, glucose should be administered intravenously. Hyponatremia, which is reduced serum sodium below the laboratory references ranges, may present with seizures; however, none are evident in this case. Hypokalemia, which is reduced serum potassium below the laboratory reference ranges, may present with muscular weakness; however, that is not a listed symptom. Hypocalcemia, which is reduced serum calcium below the laboratory reference ranges, may present with neuromuscular hyperirritability; it is not mentioned in this case. Hypovolemia, which is reduced circulating volume, may present with cardiovascular collapse verging on shock. This patient is not in such a condition. Hypomagnesemia, which commonly results from poor nutrition, would be unlikely in this setting. Hypothermia, which is reduced body temperature, may present with slow mentation; it is not a condition pertinent to this case. The core ethical and legal principle is to be reasonably certain that all efforts have been provided. Afterwards, it is important to identify, diagnose, treat, and correct all acute medical issues and crises before simply providing injections of intra-muscular, anti-agitation, and/or anti-psychotic medications that necessarily carry an element of risk and are of no benefit in this setting. A 45-year-old man presents with multiple symptoms, including a 2-year history of chronic fatigue, headaches, and joint pain. He was finally prompted to seek care when he noticed an increase in both his hat and shoe size. His past medical history is unremarkable, with no known medical conditions; there is no history of surgery, and he does not take any medications. He lives with his girlfriend, and he works as a building contractor. On physical exam, his facial features appear "coarse"; he has a wide nose, and macroglossia is noted. The remainder of his physical exam is normal, and no observable abnormalities are noted on the patient's head or feet. Several tests are performed and significant findings include: Growth hormone: Elevated Oral glucose tolerance test (OGTT): Elevated glucose levels Insulin-like growth factor-1 (IGF-1): Elevated Question After treatment of this patient's condition is initially completed, for what complication of this condition should he be monitored? Answer Choices 1 Cardiovascular disease 2 Hypogammaglobulinemia 3 Multiple myeloma 4 Osteoporosis 5 Parkinson disease - ✔✔Cardiovascular Disease Explanation This patient is presenting with acromegaly, a rare disorder of excess growth hormone (GH), most often caused by a GH-secreting pituitary adenoma. Because the changes are insidious, patients may take years to present with symptoms and be diagnosed. The patient and close family members may not notice the acral skeletal growth enlargement, unless it affects the fit of shoes, rings and/or hats. Other possible signs and symptoms of acromegaly include fatigue, headaches, visual field deficits, hypertension, coarse facial features, carpal tunnel syndrome, and joint pain. Treatment may include surgical resection of the adenoma, medications or radiation. Patients with acromegaly are at risk for early death; the primary cause of death is cardiovascular disease. Patients with acromegaly may develop hypertension, cardiomyopathy, and hypertrophy. Hypogammaglobulinemia is an immune disorder in which the affected patient has reduced levels of immunoglobulins and is at risk for infection. Hypogammaglobulinemia, and other immune system disorders, are not identified as acromegaly complications. Multiple myeloma is a plasma cell cancer that affects bone marrow. While acromegaly does affect bone growth, it has not been linked with bone malignancy. Osteoporosis is the demineralization of bone structure, leading to bone weakness and fracture. It is not considered a complication of acromegaly. Parkinson disease is a chronic, progressive neurologic disorder associated with tremor, rigidity, abnormal gait, and mental changes, such as dementia and depression. Patients with acromegaly are not known to be at a higher risk of Parkinson disease. A 54-year-old man is discovered to have hypertension (165/110 mm Hg) on a routine physical exam. On questioning, the patient reveals that he had been suffering from headaches and leg cramps in addition to a feeling of generalized weakness. A careful history further reveals an increased urinary volume. Complete investigations show hypokalemic alkalosis with high serum sodium (154 mEq/L) and low serum potassium (2-4 mEq/L). The ECG shows flattened T waves, long QT, and U waves. The lab reports also show low plasma renin. What is the likely diagnosis? Answer Choices 1 Primary hyperaldosteronism 2 Secondary hyperaldosteronism 3 Primary hypoaldosteronism 4 Secondary hypoaldosteronism 5 Cushing's Syndrome - ✔✔Primary Hyperaldosteronism Explanation Primary and secondary hyperaldosteronism are both characterized by increased aldosterone production from the adrenal cortex. Primary hyperaldosteronism results from adrenal adenomas (Conn's Syndrome) in 60% of cases. 30% are due to bilateral adrenal hyperplasia. Secondary hyperaldosteronism results from increased activation of the renin-angiotensin system, leading to intensive stimulation of the adrenal cortex. Secondary hyperaldosteronism is generated by extravascular loss of Na+ and water (e.g. cirrhosis, nephrosis, congestive heart failure), renal artery stenosis, or by tumor of the juxtaglomerular cells. Renin secretion from the juxtaglomerular cells is increased under these conditions, leading to increased formation of angiotensin II. Thus, in secondary hyperaldosteronism, both renin and angiotensin levels are high. In primary hyperaldosteronism the renin and angiotensin levels are low, being reduced by the expansion of the extracellular space. Aldosterone stimulates K+ secretion in the kidney; therefore, plasma K+ level is decreased in both primary and secondary hyperaldosteronism. Plasma Na+ level is usually within the physiological range, because the increased Na+ reabsorption is always followed by increased water accumulation. The plasma level of angiotensinogen is normal in both primary and secondary hyperaldosteronism. A 24-year-old woman has recently been diagnosed with insulin-dependent diabetes. The disease is being managed on a split dose of 60/40 insulin suspension, which she injects herself at 8:00 a.m. and 5:00 p.m. She was told to call in if she experiences any strange symptoms, which she does this afternoon. At 2:45 p.m., she is not feeling well and notices that her skin is cool and damp. Her hands are shaking and she is very anxious. What do you tell her to do right away, before having somebody take her to your office? Answer Choices 1 Inject 4 IU of her insulin 2 Drink a can of diet soda 3 Drink four ounces of fruit juice 4 Eat a large candy bar 5 Eat a cube of sugar - ✔✔Drink 4 ounces of fruit juice Explanation The above described symptoms are classical for hypoglycemia. An inexperienced patient needs to be monitored by medical personnel until the blood glucose level is stabilized again. The first priority, though, is to prevent the blood sugar to drop any further and send the patient into a coma. A four-ounce drink of fruit juice should be sufficient. Since diet soda contains only sugar substitutes, it is not going to influence the blood glucose level. A large candy bar could be eaten too, but it may raise the glucose level higher than required. Therefore, the fruit juice is a better choice. 1 cube of sugar is an insufficient amount to raise blood sugar; it will take several cubes. According to the American Diabetes Association, 15-20grams of carbohydrates are recommended. Since the symptoms suggest hypoglycemia, injecting insulin would worsen the situation. If unsure whether the patient is hypo- or hyperglycemic, and there is no possibility for a test, always give sugar first and see if the patient improves. An increase of a blood glucose level of, for example, 350 is not going to hurt the patient; however, lowering a [Show More]
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