ESAP-ITE 2016 Slide Set - the Endocrine Society Center for Learning

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ESAP-ITE 2016 Questions
Slide Set
Question 1:Thyroid Disorders
A primary care physician refers a 58-year-old woman to you after a thyroid nodule was
documented on chest CT that was done for evaluation of a chronic cough. The radiologist
mentioned an incidental 1.5-cm nodule in the right lower lobe of the thyroid gland. The
patient has no history of thyroid disease and no history of external radiation treatment to
the head or neck as a child. She has no family history of thyroid disease. She has no pain
or tenderness in the anterior neck; no dyspnea, dysphagia, or dysphonia; and no
symptoms suggestive of hyperthyroidism or hypothyroidism.
On physical examination, the thyroid is normal in size and consistency and no nodules
are palpated.
Laboratory studies reveal a TSH concentration of 1.9 mIU/L (reference range, 0.5-5.0
mIU/L).
Thyroid ultrasonography demonstrates 2 adjacent right lower pole nodules: a mixed
cystic, solid, noncalcified, 0.8-cm nodule and a 0.5-cm, hypoechoic, noncalcified, solid
nodule. There is also a 10-mm pure cyst noted in the upper left lobe of the thyroid.
1
Which of the following is the best approach?
A. Perform a thyroid scan using radioactive iodine (123I)
B. Treat with levothyroxine at a dosage that suppresses serum TSH,
then perform thyroid ultrasonography again in 4 to 6 months
C. Perform thyroid ultrasonography again in 1 year
D. Perform ultrasound-guided fine-needle aspiration biopsy of the right
solid nodule
E. Perform ultrasound-guided fine-needle aspiration to drain the fluid
from the left cyst
Learning objective:
Manage incidentally discovered thyroid nodules.
2
Question 2: Diabetes Mellitus and
Other Carbohydrate Disorders
A 32-year-old woman with polycystic ovary syndrome delivered a baby 2 years
ago. During that pregnancy, she was treated for gestational diabetes with
dietary restriction and was able to maintain her fingerstick blood glucose levels
within the targeted range and her hemoglobin A1c level less than 6.0% (<42
mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol]). After delivery, her
glycemia normalized. Twelve weeks postpartum, her 2-hour plasma glucose
value during a follow-up oral glucose tolerance test was documented to be 136
mg/dL (7.5 mmol/L). She just learned that she is pregnant and presents for
evaluation.
3
Which of the following should you recommend?
A. No intervention now; screen with oral glucose tolerance testing at
24 to 28 weeks for gestational diabetes
B. Screen with oral glucose tolerance testing now and again at 24
to 28 weeks for gestational diabetes
C. Screen with hemoglobin A1c measurement now and with oral
glucose tolerance testing at 24 to 28 weeks for gestational diabetes
D. Screen with hemoglobin A1c measurement and fasting blood
glucose now; this is adequate since she had gestational diabetes in
the past
E. Start self-monitoring of blood glucose before and 2 hours after
meals
Learning objective:
Diagnose gestational diabetes.
4
Question 3: Bone and Mineral
Metabolism
Osteoporosis was diagnosed in a 62-year-old postmenopausal woman 7 years ago, and she has taken
weekly alendronate therapy since that time. She took hormone therapy for hot flashes from age 52 to 60
years (overlapping with the alendronate therapy for 5 years). She has been adherent to her calcium and
vitamin D regimen.
She had been walking 20 minutes 3 times weekly but stopped due to left leg pain with weight bearing 3
months ago. There had been no change in her exercise pattern or frequency before the pain started. At
that time, her primary care physician gave her crutches and prescribed no weight bearing for 3 months.
Despite this rest period, her left leg continues to hurt.
Physical examination findings are unremarkable other than an antalgic gait. She has no pain in the
contralateral thigh.
Plain film of the left femur is shown (see image).
5
Which of the following is the best treatment
recommendation for this patient?
A. Discontinue alendronate and refer to orthopedic surgery
B. Discontinue alendronate and start teriparatide
C. Discontinue alendronate and change to an intravenous
bisphosphonate
D. Continue alendronate
E. Continue alendronate and restart hormone therapy
Learning objective:
Manage an atypical femur fracture associated with prolonged
bisphosphonate use.
6
Question 4:Female Reproduction
A 25-year-old woman with polycystic ovary syndrome comes to you for follow-up 2 years after
her last visit. Her initial symptoms included hirsutism, acne, hyperandrogenemia, and irregular
menses. These symptoms have been treated with hormonal contraception and she is pleased
with the result. She has always been overweight, with her maximum BMI being greater than 40
kg/m2. An oral glucose tolerance test 7 years ago diagnosed impaired glucose tolerance. In
addition to the oral contraceptive, metformin, 1000 mg twice daily, was prescribed. Over the
last 2 years, she has dramatically changed her diet by decreasing carbohydrates and
eliminating processed foods. She also began walking 30 minutes daily. She appears thin at her
visit today.
On physical examination, her blood pressure is 102/80 mm Hg. Her height is 59 in (149.9 cm),
and weight is 103 lb (46.8 kg) (BMI = 20.8 kg/m2). Her waist circumference is 27.6 in (70 cm).
She has loose skin over her body. Her Ferriman-Gallwey score is 11 (normal, <9). She has no
acne and only mild acanthosis is still visible in the axillae. Her thyroid gland is normal.
7
Laboratory test results:
Testosterone = 41 ng/dL (1.4 nmol/L) (reference range, 8-60 ng/dL [0.3-2.1 nmol/L])
Total cholesterol = 209 mg/dL (5.41 mmol/L) (reference range [optimal], <200 mg/dL
[5.18 mmol/L])
Triglycerides = 158 mg/dL (1.79 mmol/L) (reference range [optimal], <150 mg/dL [<3.88
mmol/L])
LDL cholesterol = 89 mg/dL (2.31 mmol/L) (reference range [optimal], <100 mg/dL
[<2.59 mmol/L])
HDL cholesterol = 89 mg/dL (2.31 mmol/L) (reference range [optimal], >60 mg/dL
[>1.55 nmol/L])
Hemoglobin A1c = 5.1% (32 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
8
Which of the following is the most appropriate change to be
made to her treatment regimen?
A.
B.
C.
D.
E.
Stop metformin
Stop the oral contraceptive
Add spironolactone
Add fenofibrate
Add finasteride
Learning objective:
Determine the most appropriate use of metformin in women with
polycystic ovary syndrome.
9
Question 5:Adrenal Disorders
A 21-year-old woman is referred to you with new-onset hypertension, increased
sweating, headaches, and occasional palpitations and abnormal findings on
abdominal CT. Her father has a history of bilateral pheochromocytoma for
which he underwent bilateral adrenalectomy at age 41 years. She is currently
taking losartan, 100 mg daily, and amlodipine, 5 mg daily. Her menstrual cycles
are normal and she is not sexually active.
On physical examination, her blood pressure is 142/92 mm Hg and pulse rate
is 86 beats/min. Her height is 65 in (165.1 cm), and weight is 144 lb (65.5 kg)
(BMI = 24.0 kg/m2). She is noncushingoid and appears healthy. There are no
café-au-lait spots. Her fundoscopic examination shows retinal angiomas. Her
thyroid gland and the rest of her physical findings are normal.
10
Laboratory test results:
Electrolytes, normal
Aldosterone = 3 ng/dL (83.2 pmol/L) (reference range, 1-21 ng/dL [27.7-582.5
pmol/L])
Plasma renin activity = 8.2 ng/mL per h (reference range, 0.6-4.3 ng/mL per h)
Serum cortisol = 12.1 μg/dL (333.8 nmol/L) (reference range, 5-25 μg/dL
[137.9-689.7 nmol/L])
Serum cortisol after 1 mg of dexamethasone = 0.9 μg/dL (24.8 nmol/L)
Serum calcitonin = 2.0 pg/mL (0.58 pmol/L) (reference range, <8 pg/mL [<2.34
pmol/L])
Plasma fractionated metanephrines:
Plasma free metanephrine = 0.08 pg/mL (0.4 nmol/L) (reference range, <57
pg/mL [<289 pmol/L])
Plasma free normetanephrine = 2.8 pg/mL (15.4 nmol/L) (reference range,
<148 pg/mL [<808 pmol/L])
11
Laboratory test results continued:
Urinary epinephrine = 15 μg/24 h (81.8 nmol/d) (reference range, <35 μg/24 h
[<191 nmol/d])
Urinary norepinephrine = 919 μg/24 h (5435 nmol/d) (reference range, <170
μg/24 h [<1005 nmol/d])
Urinary metanephrine = 65 μg/24 h (329.6 nmol/d) (reference range, <400
μg/24 h [<2028 nmol/d])
Urinary normetanephrine = 4432 μg/24 h (24,198.7 nmol/d) (reference range,
<900 μg/24 h [<4914 nmol/d])
Urinary creatinine = 1.13 g/24 h (10.0 mmol/d) (reference range, 1.0-2.0 g/24 h
[8.8-17.7 mmol/d])
Abdominal CT documents bilateral adrenal nodules. The right nodule (32
Hounsfield units) is 4.1 cm in maximum diameter, and the left nodule (23
Hounsfield units) is 0.8 cm in maximum diameter.
12
Which of the following disorders most likely explains the
imaging and biochemical abnormalities in this woman?
A. Multiple endocrine neoplasia type 2A associated with a RET protooncogene mutation
B. Carney complex associated with a PRKAR1A mutation
C. Familial paraganglioma/pheochromocytoma associated with
an SDHC mutation
D. Von Hippel-Lindau syndrome associated with a VHL mutation
E. Macronodular adrenal hyperplasia associated with
an ARMC5 mutation
Learning objective:
Differentiate among hereditary syndromes associated with bilateral
pheochromocytoma on the basis of metabolic profiles.
13
Question 6:Diabetes Mellitus and
Other Carbohydrate Disorders
A 56-year-old man with type 2 diabetes mellitus complicated by peripheral
neuropathy and microalbuminuria returns for follow-up. His current medication
regimen includes metformin, 1000 mg twice daily; insulin glargine, 65 units
twice daily; and insulin aspart, 80 units 3 times daily with meals.
Laboratory test result:
Hemoglobin A1c = 7.8% (62 mmol/mol) (reference range, 4.0%-5.6% [20-38
mmol/mol])
14
You plan to change his regimen to U500 regular insulin.
Which of the following is the best U500 regimen to
recommend?
A.
B.
C.
D.
E.
0.2 mL (100 units) 2 times daily before meals
0.15 mL (75 units) 3 times daily before meals
0.2 mL (100 units) 3 times daily before meals
0.25 mL (125 units) 3 times daily before meals
0.3 mL (150 units) 3 times daily before meals
Learning objective:
Guide conversion from a U100 to a U500 regular insulin regimen in a patient
with severe insulin resistance.
15
Question 7:Lipids/Obesity
A 46-year-old woman with a history of polycystic ovary syndrome comes to
your office frustrated by her weight-loss efforts. For the past month, she and
her husband have been using a Web-based tool to track their eating and
activity, and she says they have been making more healthful food choices by
selecting lower-fat alternatives. They have started an exercise program,
walking for 30 to 45 minutes 4 to 5 times weekly. Her husband has lost 6 lb (2.7
kg), but she has lost no weight. She is wondering what is wrong with her
metabolism. She is otherwise healthy and her only medication is an oral
contraceptive. She continues to have regular menses.
On physical examination, her height is 65 in (165.1 cm) and weight is 180 lb
(81.8 kg) (BMI = 30 kg/m2). Her pulse rate is 76 beats/min, and blood pressure
is 137/80 mm Hg. Examination findings are otherwise unremarkable.
Specifically, she has no thyroid enlargement and no cushingoid features.
Laboratory test result:
TSH = 6.1 mIU/L (reference range, 0.5-5.0 mIU/L)
16
Which of the following is the most likely factor contributing
to this patient's lack of weight loss?
A.
B.
C.
D.
E.
Insufficient caloric restriction
Insufficient exercise
Hypothyroidism
Oral contraceptive therapy
Polycystic ovary syndrome
Learning objective:
Prioritize calorie restriction to achieve weight loss.
17
Question 8:Male Reproduction
You are asked to consult on a 64-year-old man for low serum testosterone
levels. The patient is currently in the rehabilitation unit. He was well until 4
weeks ago when he presented to the emergency department with a productive
cough and fever. Lobar pneumonia was diagnosed and soon after hospital
admission, he developed respiratory distress necessitating intubation and
transfer to the intensive care unit. He was transferred to the floor 9 days later
and then to the rehabilitation unit for the past week. Although overall his
condition has improved, he reports fatigue and exhaustion.
Laboratory evaluation shows normal levels of morning cortisol, prolactin, and
TSH; however, his total testosterone concentration is low at 127 ng/dL (4.4
nmol/L) (reference range, 300-900 ng/dL [10.4-31.2 nmol/L]).
The patient is married and has 3 biologic children. He has no known history of
gonadal problems.
18
On physical examination, the patient looks deconditioned and tired. His pulse
rate is 82 beats/min, and blood pressure is 119/59 mm Hg. His height is 70 in
(177.8 cm), and weight is 192 lb (87.3 kg) (BMI = 27.5 kg/m2). He has lost 10
lb (4.5 kg) since hospital admission. His visual fields are normal to
confrontation. His testes are 20 mL bilaterally. His muscle mass and power are
reduced.
Additional laboratory test results:
Repeated morning serum total testosterone (by tandem mass spectrometry) =
140 ng/dL (4.9 nmol/L) (reference range, 300-900 ng/dL [10.4-31.2 nmol/L])
LH = 2.3 mIU/mL (2.3 IU/L) (reference range, 1.0-9.0 mIU/mL [1.0-9.0 IU/L])
Serum albumin = 3.8 g/dL (38 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
19
Which of the following is the most appropriate next step in
this patient's evaluation?
A.
B.
C.
D.
E.
Free testosterone measurement
Total testosterone measurement in 6 to 8 weeks
Pituitary-directed MRI
FSH measurement
Sex hormone-binding globulin measurement
Learning objective:
Assess the effects of acute illness on the hypothalamic-pituitary-gonadal axis.
20
Question 9:Pituitary and
Neuroendocrine Disorders
A 20-year-old man is transferred to your care from his pediatric endocrinologist
because the patient is embarrassed to sit in a waiting room with small children.
He has a diagnosis of isolated, idiopathic GH deficiency, and he states that he
experienced a substantial increase in height after he started GH treatment at
age 8 years. He stopped growing several years ago and wonders if he should
still be taking GH therapy.
21
Which of the following would you advise now regarding GH
therapy?
A.
B.
C.
D.
E.
Continue GH therapy
Stop GH therapy and measure GH and IGF-1 in one month
Stop GH therapy and measure GH and IGF-1 in one year
Stop GH therapy and perform GH stimulation test in one month
Stop GH therapy and perform GH stimulation test in one year
Learning objective:
To learn when and how to perform GH stimulation retesting during transition.
22
Question 10:Diabetes Mellitus and
Other Carbohydrate Disorders
You are asked to see a 65-year-old woman with rheumatoid arthritis in whom diabetes mellitus
was diagnosed about 1 month ago. Four months ago, she began taking prednisone. Currently,
she is taking 17.5 mg once daily. Before starting prednisone, her fasting serum glucose
concentration was 105 mg/dL (5.8 mmol/L) (reference range, 70-99 mg/dL (3.9-5.5 mmol/L),
and her hemoglobin A1c level was 5.7% (39 mmol/mol) (reference range, 4.0%-5.6% [20-38
mmol/mol]). After presenting with postprandial fatigue and polyuria, diabetes mellitus was
diagnosed. She met with a nutritionist and is now closely adhering to the nutritional
recommendations. Her current hemoglobin A1c measurement is 8.0% (64 mmol/mol).
Below is a typical blood glucose record for the patient:
Glucose Concentration
Day of the Week Breakfast
Monday
Tuesday
Wednesday
23
115 mg/dL
Lunch
Evening Meal Bedtime
215 mg/dL
180 mg/dL
135 mg/dL
(6.4 mmol/L) (11.9 mmol/L) (10.0 mmol/L) (7.5 mmol/L)
121 mg/dL
235 mg/dL
175 mg/dL
142 mg/dL
(6.7 mmol/L) (13.0 mmol/L) (9.7 mmol/L)
(7.9 mmol/L)
119 mg/dL
144 mg/dL
240 mg/dL
181 mg/dL
(6.6 mmol/L) (13.3 mmol/L) (10.0 mmol/L) (8.0 mmol/L)
You decide to treat her with insulin. Which of the following
would be the most appropriate regimen?
A.
B.
C.
D.
E.
NPH insulin twice daily in equal doses
Insulin glargine at bedtime
NPH insulin at bedtime
Sliding scale insulin aspart before meals
NPH and regular insulin before breakfast
Learning objective:
List the principles of treating glucocorticoid-induced diabetes.
24
Question 11:Pituitary and
Neuroendocrine Disorders
A 68-year-old man with malignant melanoma presents with fatigue, headache,
nausea, vomiting, and dizziness. He has had no fever, weight loss, vision
symptoms, abdominal pain, diarrhea, or edema. He has a history of nodular
malignant melanoma on his back, which was resected 2 years ago, with
subsequent development of pulmonary metastases. His medical history also
includes hypertension and primary hypothyroidism. His medications include
hydrochlorothiazide and levothyroxine (50 mcg daily). Three weeks ago, he had
just completed 4 cycles of ipilimumab chemotherapy (monoclonal antibody
used to treat metastatic melanoma).
On physical examination, his blood pressure is 102/64 mm Hg and pulse rate is
78 beats/min. He is afebrile, alert, and fully responsive. There are no evident
visual field deficits on confrontation testing. There is no goiter or peripheral
edema.
25
Laboratory tests results:
Sodium = 133 mEq/L (133 mmol/L) (reference range, 136-142 mEq/L [136-142 mmol/L])
Potassium = 4.1 mEq/L (4.1 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
Calcium = 8.8 mg/dL (2.2 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L])
Creatinine = 1.1 mg/dL (97.2 µmol/L) (reference range, 0.7-1.3 mg/dL [61.9-114.9 µmol/L])
Glucose = 72 mg/dL (4.0 mmol/L) (reference range, 70-110 mg/dL [3.9-6.1 mmol/L])
Prolactin = 42 ng/mL (1.8 nmol/L) (reference range, 4-23 ng/mL [0.17-1.00 nmol/L])
IGF-1 = 52 ng/mL (6.8 nmol/L) (reference range, 67-195 ng/mL [8.8-25.5 nmol/L])
TSH = 0.02 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 0.8 ng/dL (10.3 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
Serum cortisol (8 AM) = 2.8 µg/dL (77.2 nmol/L) (reference range, 5-25 µg/dL [137.9-689.7
nmol/L]), rising to a peak cortisol level of 19.0 µg/dL (524.2 nmol/L) after the administration of
250 mcg cosyntropin
Testosterone = 80 ng/dL (2.8 nmol/L) (reference range, 300-900 ng/dL [10.4-31.2 nmol/L])
LH = 0.2 mIU/mL (0.2 IU/L) (reference range, 1.0-9.0 mIU/mL [1.0-9.0 IU/L])
FSH = 0.4 mIU/mL (0.4 IU/L) (reference range, 1.0-13.0 mIU/mL [1.0-13.0 IU/L])
Urinary sodium = 32 mEq/L (32 mmol/L) (reference range, 40-217 mEq/24h [40-217 mmol/d])
Urinary osmolality = 420 mOsm/kg (420 mmol/kg) (reference range, 150-1150 mOsm/kg [1501150 mmol/kg])
26
Brain MRI shows mild, diffuse pituitary enlargement without evidence of
compression of the optic apparatus (see image).
27
Which of the following is the most appropriate next step?
A.
B.
C.
D.
E.
Refer for transsphenoidal surgery
Refer for radiation therapy
Administer glucocorticoids
Decrease the levothyroxine dosage
Prescribe cabergoline therapy
Learning objective:
Identify and manage ipilimumab-induced hypophysitis.
28
Question 12:Adrenal Disorders
A 62-year-old woman is referred for further evaluation of an adrenal mass that
was discovered after she underwent abdominal CT to investigate possible renal
calculi. The mass measures 2.8 x 2.2 cm and has a density of -10 Hounsfield
units without contrast. The patient has a history of hypertension treated with
amlodipine. She takes no other medications.
On physical examination, her height is 66 in (167.6 cm) and weight is 180 lb
(81.8 kg) (BMI = 29 kg/m2). Her blood pressure is 142/89 mm Hg (supine). She
has evidence of nonviolaceous striae across her abdominal wall.
29
Laboratory test results:
Glucose = 140 mg/dL (7.8 mmol/L) (reference range, 70-99 mg/dL [3.9-5.5
mmol/L])
Plasma renin activity = 3.5 ng/mL per h (reference range, 0.6-4.3 ng/mL per h)
Aldosterone = 17 ng/dL (471.6 pmol/L) (reference range, 1-21 ng/dL [27.7285.5 pmol/L])
ACTH = 12 pg/mL (2.6 pmol/L) (reference range, 10-60 pg/mL [2.2-13.2
pmol/L])
DHEA-S = 5 µg/dL (0.14 µmol/L) (reference range, 15-157 µg/dL [0.41-4.25
µmol/L])
Serum cortisol (8 AM; 1-mg overnight dexamethasone suppression test) = 5.4
µg/dL (150.0 nmol/L) (reference range, <1.8 µg/dL [<49.7 nmol/L])
Urinary metanephrine = 281 µg/24 h (1425 nmol/d) (reference range, <400
µg/24 h [<2028 nmol/d])
Urinary normetanephrine = 578 µg/24 h (3418 nmol/d) (reference range, <900
µg/24 h [4914 nmol/d])
Urinary cortisol = 68 µg/24 h (187.7 nmol/L) (reference range, 4-50 µg/24 h [11138 nmol/d])
30
Which of the following is the most appropriate next
investigation?
A.
B.
C.
D.
E.
Corticotropin-releasing hormone test
DXA scan
Repeated screening tests for cortisol excess in 6 months
High-dose (8-mg) dexamethasone suppression test
Adrenal-directed MRI
Learning objective:
Order a comprehensive evaluation in the setting of subclinical Cushing
syndrome to help determine whether surgery is appropriate.
31
Question 13: Bone and Mineral
Metabolism
You are seeing a 72-year-old woman who has had several serum calcium
measurements in the range of 10.9 to 11.5 mg/dL (2.7-2.9 mmol/L) (reference
range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L]). Her serum albumin level is normal.
Her kidney function is modestly reduced (estimated glomerular filtration rate, 41
mL/min). Her serum PTH level is 54 pg/mL (54 ng/L) (reference range, 10-65
pg/mL [10-65 ng/L]), and urinary calcium excretion is 410 mg/24 h (10.3
mmol/d) (reference range, 100-300 mg/24 h [2.5-7.5 mmol/d]). A sestamibi
parathyroid scan and neck ultrasound did not identify any parathyroid
abnormalities.
32
Which of the following should be the next step in this
patient's management?
A.
B.
C.
D.
E.
Perform minimally invasive parathyroidectomy
Perform parathyroidectomy after neck exploration
Measure 1,25-dihydroxyvitamin D
Prescribe hydrochlorothiazide, 12.5 mg daily
Perform another sestamibi scan in 6 months
Learning objective:
Recognize that inappropriately normal parathyroid hormone is consistent with
hyperparathyroidism and use the guidelines for surgery (decreased glomerular
filtration rate) in management decisions.
33
Question 14:Thyroid Disorders
A 58-year-old woman with stage IV medullary thyroid cancer is referred for
consideration of further therapy. Medullary thyroid cancer was diagnosed 8
years earlier and she has had persistent postoperative serum calcitonin
elevation. Distant metastases to the lungs and ribs were detected 1 year ago,
with disease progression over the past 6 months. Physical examination reveals
a well-healed thyroidectomy scar but findings are otherwise unremarkable.
Laboratory test results:
Serum calcitonin = 15,000 pg/mL (4380 pmol/L) (reference range, <8 pg/mL)
[<2.3 pmol/L])
Carcinoembryonic antigen = 65 ng/mL (65 µg/L) (reference range, <2.5 ng/mL
[<2.5 µg/L])
34
Which of the following is the most appropriate next step in
this patient's management?
A.
B.
C.
D.
E.
Tyrosine kinase inhibitor therapy
Chemotherapy with adriamycin and cisplatin
Radiotherapy to the lung and rib lesions
Radiolabeled anticalcitonin antibody therapy
Prophylactic whole-brain radiotherapy
Learning objective:
To review indications for tyrosine kinase inhibitor therapy in advanced
medullary thyroid cancer.
35
Question 15: Diabetes Mellitus and
Other Carbohydrate Disorders
You evaluate a 28-year-old woman with type 1 diabetes mellitus who is
estimated to be 8 weeks pregnant. Her diabetes is complicated by retinopathy,
albuminuria, and hypertension treated with an ACE inhibitor (which has been
stopped by her primary care physician). She is using a combination of basal
insulin with fixed prandial doses of rapid-acting insulin analogue. She also
takes a statin to treat elevated LDL cholesterol; she has a strong family history
of early coronary artery disease. Her blood pressure is 146/90 mm Hg, and her
fasting blood glucose values range between 110 and 122 mg/dL (6.1-6.8
mmol/L) (reference range, 70-99 mg/dL [3.9-5.5 mmol/L]).
36
Which of the following should you recommend?
A.
B.
C.
D.
Stop the statin now and resume in the second trimester
Start losartan for treatment of albuminuria and hypertension
Switch to insulin pump therapy
Maintain overnight glucose levels between 60 and 99 mg/dL (3.3-5.5
mmol/L)
E. Refer for retinal evaluation in the third trimester of pregnancy
Learning objective:
To know basic recommendations for glycemic control in pregnancy.
37
Question 16: Female Reproduction
A 25-year-old woman with polycystic ovary syndrome presents to discuss
contraceptive options. Menarche was at age 11 years, and her menses have
always been irregular. She had onset of hirsutism and acne at age 12 years
and both have progressed since adolescence. She is taking spironolactone, 75
mg daily, and metformin, 500 mg twice daily before meals.
On physical examination, her height is 64 in (162.6 cm) and weight is 170 lb
(77.3 kg) (BMI = 29.2 kg/m2). Her blood pressure is 110/70 mm Hg. She has
mild facial hirsutism and acne without temporal balding. There is no evidence of
striae or hyperpigmentation. Her free testosterone concentration is elevated at
5.3 ng/dL (0.18 nmol/L) (reference range, 0.3-1.9 ng/dL [0.01-0.07 nmol/L]).
38
Which of the following contraceptive methods would be
best for this patient?
A.
B.
C.
D.
E.
Levonorgestrel-releasing intrauterine device
Oral ethinyl estradiol
Medroxyprogesterone
Oral contraceptive containing norethindrone
Transdermal contraceptive patch
Learning objective:
Differentiate among contraceptive options for women with polycystic ovary
syndrome.
39
Question 17: Lipids/Obesity
A 58-year-old man is referred for management of dyslipidemia. He has a history
of coronary artery disease, type 2 diabetes mellitus, and hypertension. He had
been on simvastatin, but 4 months ago, he was noted to have abnormalities in
plasma liver enzyme levels, and simvastatin was discontinued. Recent
measurement of his lipids shows a return of hyperlipidemia despite renewed
efforts at dietary restraint.
40
Analyte
Total cholesterol
Triglycerides
LDL cholesterol
HDL cholesterol
4 Months Ago
2 Weeks Ago
Reference Ranges
161 mg/dL
253 mg/dL
Optimal, <200 mg/dL
(4.17 mmol/L)
(6.55 mmol/L)
(<5.18 mmol/L)
232 mg/dL
216 mg/dL
Optimal, <150 mg/dL
(2.62 mmol/L)
(2.44 mmol/L)
(<3.88 mmol/L)
72 mg/dL
166 mg/dL
Optimal, <100 mg/d
(1.86 mmol/L)
(4.30 mmol/L)
(<2.59 mmol/L)
41 mg/dL
44 mg/dL
Optimal, >60 mg/dL
(1.06 mmol/L)
(1.14 mmol/L)
(>1.55 mmol/L)
Alanine
126 U/L
77 U/L
10-40 U/L
aminotransferase
(2.10 µkat/L)
(1.29 µkat/L)
(0.17-0.67 µkat/L)
Aspartate
91 U/L
59 U/L
20-48 U/L
aminotransferase
(1.52 µkat/L)
(0.99 µkat/L)
(0.33-0.80 µkat/L)
1.1 mg/dL
1.0 mg/dL
0.3-1.2 mg/dL
(18.8 µmol/L)
(17.1 µmol/L)
(5.1-20.5 µmol/L)
84 U/L
88 U/L
50-120 U/L
(1.4 µkat/L)
(1.5 µkat/L)
(0.84-2.00 µkat/L)
7.1%
6.9%
4.0%-5.6%
(54 mmol/mol)
(52 mmol/mol)
(20-38 mmol/mol)
Total bilirubin
Alkaline phosphatase
Hemoglobin A1c
He does not smoke cigarettes and drinks fewer than 5 alcohol-containing beverages per week.
Current medications include metformin, lisinopril, hydrochlorothiazide, and aspirin. There is no history
of hepatitis and results of serologic tests for hepatitis viruses are negative. Abdominal
ultrasonography shows a hyperechoic pattern of the liver parenchyma, no dilation of the hepatic
ducts, and no masses.
On physical examination, he is moderately obese with a BMI of 33.2 kg/m2 (height is 69 in [175.3
cm], and weight is 225 lb [102.3 kg]). Blood pressure is 128/79 mm Hg. There is no jaundice,
hepatomegaly, or edema.
41
Which of the following is the best next step in this patient's
care?
A.
B.
C.
D.
E.
Re-start simvastatin
Prescribe fenofibrate
Refer for liver biopsy
Prescribe niacin
Prescribe ezetimibe
Learning objective:
Assess the risks and benefits of HMG-CoA reductase inhibitors and their use in
preventing cardiovascular disease.
42
Question 18: Diabetes Mellitus and
Other Carbohydrate Disorders
A 25-year-old male graduate student with a 14-year history of type 1 diabetes
mellitus inquires about continuous glucose monitoring to assist with diabetes
management. He is treated with multiple daily insulin injections. He is very busy
with class work, a part-time job, and extracurricular activities and has had
difficulty monitoring his blood glucose as instructed. He worries that he has
been experiencing fairly frequent hypoglycemic episodes and does not always
have warning symptoms. He is hoping that a continuous glucose sensor will
facilitate his monitoring and improve his control. His current hemoglobin
A1c value is 8.9% (74 mmol/mol) (reference range, 4.0%-5.6% [20-38
mmol/mol]).
43
In counseling this patient, you should tell him that
continuous glucose sensor systems:
A. Effectively lower hemoglobin A1c if worn more than 50% of the time
B. Are useful only in combination with insulin pump therapy
C. Measure interstitial glucose concentrations, which lag behind capillary
glucose concentrations by about 30 minutes
D. Can replace fingerstick blood glucose monitoring
E. Automatically suggest insulin dose adjustments
Learning objective:
To understand that a valuable tool for assisting in glycemic management will be
beneficial only if the patient uses it frequently.
44
Question 19:Pituitary and
Neuroendocrine Disorders
An 18-year-old man is referred for tall stature, headaches, and sweating. His
height is 82 in (208.3 cm), and weight is 273 lb (124.1 kg), both of which are at
greater than the 97th percentile. On physical examination, he has enlarged
hands and feet and a prognathic mandible. There are no changes in skin
pigmentation and no long-bone deformities. A maternal uncle and maternal
aunt both had pituitary adenomas of uncertain type. There is no known family
history of calcium disorders or kidney stones.
45
Laboratory test results:
Random GH = 90 ng/mL (90 µg/L) (reference range, 0.01-0.97 [0.01-0.97
µg/L]) (GH does not suppress adequately during an oral glucose tolerance test)
Serum IGF-1 = 1233 ng/mL (161.5 nmol/L) (reference range, 170-640 ng/mL
[22.3-83.8 nmol/L])
Prolactin = 26 ng/dL (1.1 nmol/L) (reference range, 4-23 ng/mL [0.17-1.00
nmol/L])
Thyroid axis, normal
Adrenal axis, normal
Serum calcium, normal
The patient has a bitemporal visual field defect. MRI of the brain shows a large
pituitary adenoma (4.3 x 3.2 x 2.8 cm) with suprasellar extension, impingement
on the optic chiasm, and invasion of the right cavernous sinus.
46
A germline mutation in which of the following genes is most
likely to be responsible for the findings in this patient?
A.
B.
C.
D.
E.
GNAS (GNAS complex locus)
AIP (aryl hydrocarbon receptor interacting protein)
PTTG1 (pituitary tumor-transforming 1)
TBX19 (T-box 19 transcription factor)
MEN1 (menin)
Learning objective:
To know the gene mutations causing familial pituitary adenoma syndromes.
47
Question 20: Bone and Mineral
Metabolism
A 61-year-old woman who is asymptomatic and in apparent good health was
documented to have a serum calcium level of 10.8 mg/dL (2.7 mmol/L)
(reference range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L]) at her recent annual
examination.
Additional laboratory test results:
PTH = 89 pg/mL (89 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
25-Hydroxyvitamin D = 15 ng/mL (37.4 nmol/L) (reference range [optimal], 2580 ng/mL [62.4-199.7 nmol/L])
1,25-Dihydroxyvitamin D = 82 pg/mL (213.2 pmol/L) (reference range, 16-65
pg/mL [41.6-169.0 pmol/L])
Urinary calcium excretion = 275 mg/24 h (6.9 mmol/d) (reference range, 100300 mg/24 h [2.5-7.5 mmol/d])
48
Which of the following is the most likely diagnosis?
A. The correct diagnosis cannot be made until her vitamin D deficiency has
been corrected
B. Sarcoidosis
C. Primary hyperparathyroidism
D. Secondary hyperparathyroidism
E. Tertiary hyperparathyroidism
Learning objective:
Diagnose primary hyperparathyroidism in the setting of low 25-hydroxyvitamin
D.
49
Question 21: Lipids/Obesity
A 55-year-old woman with a history of type 2 diabetes mellitus, hypertension,
atrial fibrillation, and severe psoriasis asks your opinion regarding the over-thecounter weight-loss medication orlistat.
On physical examination, her height is 65 in (165.1 cm) and weight is 187 lb
(85 kg) (BMI = 31.1 kg/m2). Her blood pressure today is 148/95 mm Hg.
She is currently taking cyclosporine for psoriasis, warfarin for atrial fibrillation,
lisinopril for hypertension, and metformin for diabetes.
50
As you counsel this patient, you should tell her that overthe-counter orlistat:
A. Is contraindicated because of her uncontrolled hypertension
B. Could reduce the blood level of warfarin, resulting in a decreased INR
(International Normalized Ratio)
C. Could reduce the blood level of cyclosporine, resulting in a psoriasis
flare
D. Is not indicated in persons with a BMI less than 33 kg/m2
E. Is medically indicated and will most likely produce a 5% weight loss
Learning objective:
To list potential drug interactions of orlistat.
51
Question 22: Male Reproduction
A 35-year-old man is referred to you because he and his wife have failed to
conceive after 12 months of frequent unprotected intercourse. The patient has
never fathered any children. His wife, age 28 years, has a 2-year-old child from a
previous relationship. She has normal menses. The man is healthy and takes no
medications.
On physical examination, he is a well-virilized man with no gynecomastia, and
genitourinary examination documents a normal penis and 15-mL testes bilaterally
(no masses, tenderness, or induration).
Laboratory test results:
Total testosterone = 600 ng/dL (20.8 nmol/L) (reference range, 300-900 ng/dL [10.431.2 nmol/L])
FSH = 16.0 mIU/mL (16.0 IU/L) (reference range, 1.0-13.0 mIU/mL [1.0-13.0 IU/L])
LH = 3.1 mIU/mL (3.1 IU/L) (reference range, 1.0-9.0 mIU/mL [1.0-9.0 IU/L])
Seminal fluid analysis = 2.8 mL; pH, 7.4; normal fructose; no sperm
Karyotype analysis = 46,XY (no visible Yq anomalies)
52
Which of the following is the best next test in the
assessment of his infertility?
A.
B.
C.
D.
E.
Antisperm antibody assessment
Serum inhibin B measurement
Testicular ultrasonography
Serum estradiol measurement
Testicular biopsy
Learning objective:
To understand the role of testicular biopsy in the evaluation of male infertility.
53
Question 23: Bone and Mineral
Metabolism
A healthy 62-year-old man presents with pain in his upper left leg that he has
noted for 1 year, although it has been worse in the past 4 months. His
symptoms are not affected by weight bearing, are worse at night, and are only
minimally improved by nonsteroidal anti-inflammatory therapy. He takes no
other medications and has no history of skeletal or rheumatologic problems or
abnormalities of calcium metabolism.
Physical examination findings are normal except for some warmth over the
proximal region of the left thigh. He does not have impaired range of motion of
his left hip.
54
Laboratory test results:
Serum calcium = 9.5 mg/dL (2.4 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
Serum phosphorus = 4.2 mg/dL (1.4 mmol/L) (reference range, 2.3-4.7 mg/dL [0.71.5 mmol/L])
Serum albumin = 4.0 g/dL (40 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Serum alkaline phosphatase = 285 U/L (4.8 µkat/L) (reference range, 50-120 U/L
[0.84-2.00 µkat/L])
Serum creatinine = 1.1 mg/dL (97.2 µmol/L) (reference range, 0.7-1.3 mg/dL [61.9114.9 µmol/L])
Prostate-specific antigen = 1.0 ng/mL (1.0 µg/L) (reference range, <5.3 ng/mL [<5.3
µg/L])
X-rays of the left hip reveal a heterogeneous pattern of marked trabecular
thickening and focal areas of bone lysis in the left femur. The cortices are intact,
and no prominent lytic lesions are seen. The femur is not bowed, and the hip joint
space is normal. Bone scan reveals increased uptake in the proximal one-third of
the left femur. No other areas of increased uptake are seen.
55
Which of the following will provide the most benefit?
A.
B.
C.
D.
E.
Risedronate, 35 mg weekly for 6 months
Salmon calcitonin, 100 units daily by subcutaneous injection, indefintely
Alendronate, 40 mg daily for 6 months
Salmon calcitonin nasal spray, 100 units daily for 1 year
Alendronate, 70 mg weekly for 6 months
Learning objective:
Determine the appropriate treatment of Paget disease of bone.
56
Question 24: Diabetes Mellitus and Other Carbohydrate
Disorders
A 58-year-old man with a 28-year history of type 1 diabetes mellitus has been
on insulin pump therapy for 11 years. He has been experiencing recurrent,
severe, unpredictable hypoglycemia over the past year. His diabetes is
complicated by proliferative retinopathy, microalbuminuria with a stable
creatinine concentration of 1.1 mg/dL (97.2 µmol/L) for the past 3 years, and
peripheral sensory neuropathy with a history of an ulcer on his left first
metatarsal. He is now seeking evaluation for possible pancreas transplant with
the hope of avoiding future severe hypoglycemia.
57
Which of the following is the most important consideration
in deciding whether to recommend pancreas transplant in
this patient?
A. Better organ survival with pancreas transplant alone than with pancreas
transplant plus simultaneous kidney transplant
B. Better patient survival after pancreas transplant alone
C. The effect of calcineurin-based immunosuppression on insulin action
D. His frequency and severity of hypoglycemia and comorbidities
E. The potential effect of immunosuppressive therapy on renal function
Learning objective:
To know the most important indications for pancreas transplantation.
58
Question 25: Pituitary and
Neuroendocrine Disorders
A 26-year-old man is referred by his internist for suspected diabetes insipidus. He reports a
constant sense of thirst, and he believes he drinks more fluids and urinates more often than
other people.
Laboratory test results:
Fasting plasma glucose = 89 mg/dL (4.9 mmol/L) (reference range, 70-99 mg/dL [3.9-5.5
mmol/L])
Total urine volume = 7.5 L/24 h with urine osmolality of 70 mOsm/kg (70 mmol/kg) (reference
range, 150-1150 mOsm/kg [150-1150 mmol/kg])
A fluid deprivation test over 4 hours results in a 6.5-lb (3-kg) decrease in body weight, a rise in
serum sodium from 140 to 153 mEq/L (140 to 153 mmol/L), and a rise in serum osmolality from
283 to 312 mOsm/kg (283 to 312 mmol/kg). The osmolality of urine collections over this period
increases from 70 to 95 mOsm/kg (70 to 90 mmol/kg). At the end of the 4-hour period, a
subcutaneous injection of DDAVP (2 mcg) is administered, and 1 hour and 2 hours after the
injection, his urine osmolality rises to 300 and 420 mOsm/kg (300 and 420 mmol/kg),
respectively.
59
On the basis of these results, which of the following
treatments would be most effective for this patient?
A.
B.
C.
D.
E.
Amiloride
Thiazide diuretic
Indomethacin
Referral for psychiatric evaluation
DDAVP (desmopressin)
Learning objective:
To understand how to interpret the dehydration test when diagnosing diabetes
insipidus.
60
Question 26: Female Reproduction
A 24-year-old woman who runs competitive track presents with low body weight
and amenorrhea. She had normal menarche at age 11 years and regular
menses in adolescence. However, during college she lost weight and her
menses stopped 8 months ago. Her weight over the past 3 years has been
stable. She is otherwise well and has no notable medical history. She has no
headaches, altered vision, or breast tenderness or discharge.
On physical examination, her height is 65 in (165.1 cm) and weight is 115 lb
(52.3 kg) (BMI = 19.1 kg/m2). Examination findings are normal.
61
Of the following, which are the most common laboratory
test abnormalities you would expect in this patient?
A.
B.
C.
D.
E.
High FSH, high LH, low estradiol, and normal prolactin
High FSH, low LH, normal estradiol, and high prolactin
Low FSH, low LH, low estradiol, and normal prolactin
Low FSH, low LH, low estradiol, and high prolactin
Low FSH, high LH, low estradiol, and high prolactin
Learning objective:
To review the laboratory patterns in reproductive hormones in hypothalamic
amenorrhea and other reproductive disorders.
62
Question 27: Bone and Mineral
Metabolism
A 68-year-old woman has been taking alendronate, 70 mg weekly, for the past
2 years. She says that she has taken it correctly except for missing a few doses
and that she has not had any adverse effects. She had a repeated bone
density test at the same center as her initial study. The report indicates a
significant loss of bone mineral density in the spine and gains of bone mineral
density in the femoral neck and total hip. The DXA images and numeric results
are shown (see images and table).
63
Baseline
Area
BMC
BMD
Area
L1
12.24
5.52
0.451
11.92
0.504
0.423
L2
12.52
6.86
0.548
12.26
5.50
0.449
L3
14.50
8.60
0.593
12.54
6.88
0.549
L4
14.90
9.20
0.617
14.45
8.54
0.591
Total L1-L4
54.15
30.18
0.557
51.17
25.96
0.507
4.79
2.30
0.480
4.75
2.53
0.532
34.21
20.18
0.590
33.95
20.20
0.595
Femoral neck
Total hip
BMC, bone mineral content; BMD, bone mineral density.
64
Follow-up
BMC
BMD
Which of the following is your conclusion?
A.
B.
C.
D.
E.
She is not taking her alendronate correctly
She is not responding to alendronate
She has some underlying cause of secondary osteoporosis
Her spine bone mineral density was measured incorrectly
Her hip bone mineral density was measured incorrectly
Learning objective:
Carefully review DXA images and identify common technical errors.
65
Question 28: Thyroid Disorders
An 84-year-old man is referred for an elevated serum TSH value. The patient
has been in good health, with no history of thyroid dysfunction. On physical
examination, his pulse rate is 72 beats/min and he has no goiter.
Serum TSH = 6.2 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 1.1 ng/dL (14.2 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17
pmol/L])
TPO antibodies, negative
These findings are stable on repeated testing.
66
Which of the following statements is correct regarding this
patient?
A.
B.
C.
D.
E.
TSH in this range is associated with increased cardiovascular mortality
His TSH value is normal for octogenarians
Elderly patients require higher weight-based dosages of levothyroxine
He has apathetic hypothyroidism
Treatment with levothyroxine will improve his quality of life
Learning objective:
To understand age-specific normal ranges for serum thyrotropin.
67
Question 29: Diabetes Mellitus and
Other Carbohydrate Disorders
A 26-year-old nondiabetic woman whose husband has type 1 diabetes mellitus
is contemplating pregnancy and is inquiring about the risk of type 1 diabetes
developing in her child.
68
Which of the following characterizes the risk of type 1
diabetes developing in her offspring?
A.
B.
C.
D.
E.
0.1%
0.4%
6.0%
20.0%
30.0%
Learning objective:
To understand the risk of type 1 DM development in the offspring of a parent
with type 1 DM.
69
Question 30: Thyroid Disorders
A 72-year-old woman with a history of Hashimoto thyroiditis that is treated with
levothyroxine therapy is found to have a parasellar meningioma requiring surgical
resection and radiation therapy. She notes fatigue and constipation, as well as occasional
palpitations. Her pulse rate is 88 beats/min, and she has a small, firm goiter.
Laboratory test results:
TSH = 1.4 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 0.9 ng/dL (11.6 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
FSH = 4.5 mIU/mL (4.5 IU/L) (reference range, >30 mIU/mL [>30 IU/L])
LH = 5.2 mIU/mL (5.2 IU/L) (reference range, >30 mIU/mL [>30 IU/L])
Plasma cortisol (8 AM) = 14 μg/dL (386.2 nmol/L) (reference range, 5-25 μg/dL [137.9689.7 nmol/L])
IGF-1 = 65.1 ng/mL (8.53 nmol/L) (reference range, 67-195 ng/mL [8.8-25.5 nmol/L])
Prolactin = 6.5 ng/mL (0.28 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30 nmol/L])
Electrocardiogram shows occasional premature ventricular contractions.
70
Which of the following is the most appropriate next step in
this patient's management?
A.
B.
C.
D.
Continue the current levothyroxine dosage
Decrease levothyroxine, with a TSH target of 2.0 to 3.0 mIU/L
Decrease levothyroxine, with a TSH target of 3.5 to 5.0 mIU/L
Increase levothyroxine, with a free T4 target of 1.2 to 1.5 ng/dL (15.4 to
19.3 pmol/L)
E. Increase levothyroxine, with a free T4 target of 1.6 to 1.9 ng/dL (20.6 to 24.5
pmol/L)
Learning objective:
Use free T4 values rather than TSH for therapeutic targets in the management
of central hypothyroidism.
71
Question 31: Male Reproduction
A 29-year-old man is referred for evaluation of gynecomastia. He describes
normal libido and erections, but he has had painless breast enlargement since
puberty. In the past 2 to 3 years, the gynecomastia has become more
noticeable. On review of systems, he shaves once weekly and has relatively
sparse body hair. His medical history is remarkable for primary hypothyroidism
due to Hashimoto thyroiditis and a history of mumps at age 13 years.
On physical examination, his height is 72 in (182.9 cm) and weight is 170 lb
(77.3 kg) (BMI = 23.1 kg/m2). He has sparse facial hair, normal axillary hair,
Tanner stage 4 pubic hair, 4-cm bilateral gynecomastia, and no galactorrhea.
Genitourinary examination shows a normal phallus with no hypospadias and 2mL testes that are very firm.
72
Laboratory test results:
Total testosterone = 225 ng/dL (7.8 nmol/L) (reference range, 300-900 ng/dL
[10.4-31.2 nmol/L])
FSH = 48.0 mIU/mL (48.0 IU/L) (reference range, 1.0-13.0 mIU/mL [1.0-13.0
IU/L])
LH = 27.0 mIU/mL (27.0 IU/L) (reference range, 1.0-9.0 mIU/mL [1.0-9.0 IU/L])
73
Which of the following is the most likely cause of this
patient's clinical presentation?
A.
B.
C.
D.
E.
Partial androgen insensitivity
Gonadotropin-producing adenoma
Klinefelter syndrome
Autoimmune polyglandular deficiency syndrome
Primary hypogonadism due to mumps orchitis
Learning objective:
To recognize the clinical and biochemical manifestations of Klinefelter
syndrome.
74
Question 32: Diabetes Mellitus and
Other Carbohydrate Disorders
A 20-year-old man with type 1 diabetes mellitus describes a several-month
history of diarrhea, unintentional weight loss, poor glycemic control, and a rash.
On physical examination, he has no abdominal tenderness, a normal 10-g
monofilament test, and a rash (see image).
75
Which of the following is the best initial diagnostic test to
evaluate his concerns?
A.
B.
C.
D.
E.
IgA tissue transglutaminase antibody measurement
Gastric emptying study
TPO antibody measurement
Colonoscopy
Skin biopsy
Learning objective:
To know the characteristic skin rash and other signs and symptoms associated
with celiac disease.
76
Question 33:Bone and Mineral
Metabolism
A 50-year-old woman is referred for evaluation of metabolic bone disease. She has
a 4-year history of progressive bone pain and recurrent fractures, including 2 pelvic
fractures with falls, a right distal radius fracture, multiple rib fractures, compression
fractures of 6 different vertebral bodies resulting in a marked kyphosis, and 3
separate metatarsal fractures. She has developed myalgias and muscle weakness.
She walks short distances with great discomfort. Recently, she was found to have a
fracture of the medial aspect of the left proximal femur. Each fracture has healed,
but she has marked residual pain that is increasing with subsequent events.
She takes no medications. She has no family history of metabolic bone disease (no
fractures or disorders of calcium metabolism), and, aside from the last 4 years, she
has no notable medical history in earlier adulthood or childhood. She has 3 healthy
children.
On physical examination, there is tenderness over both thighs, but examination
findings are otherwise normal.
77
Laboratory test results:
Calcium = 9.5 mg/dL (2.4 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
Albumin = 3.9 g/dL (39 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Creatinine = 0.8 mg/dL (70.7 µmol/L) (reference range, 0.6-1.1 mg/dL (53.0-97.2
µmol/L)
Phosphorus = 1.2 mg/dL (0.4 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5
mmol/L])
Alkaline phosphatase = 305 U/L (5.1 µkat/L) (reference range, 50-120 U/L [0.842.00 µkat/L])
Intact PTH = 52 pg/mL (52 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
25-Hydroxyvitamin D = 35 ng/mL (87.4 nmol/L) (reference range [optimal], 25-80
ng/mL [62.4-199.7 nmol/L])
1,25-Dihydroxyvitamin D = 10 pg/mL (26 pmol/L) (reference range, 16-65 pg/mL
[41.6-169.0 pmol/L])
Her tubular reabsorption of phosphate is 54% (normal, >85%). A transiliac bone
biopsy is done after double tetracycline labeling. Evaluation of the nondecalcified
specimen reveals excess osteoid and diminished tetracycline uptake.
78
Which of the following is the most likely diagnosis?
A.
B.
C.
D.
E.
Calcium malabsorption
Tumor-induced osteomalacia
Autosomal dominant hypophosphatemic rickets
X-linked hypophosphatemic rickets
Mutation in the gene encoding the vitamin D receptor
Learning objective:
Diagnose tumor-induced osteomalacia on the basis of clinical and biochemical
findings.
79
Question 34:Thyroid Disorders
An 83-year-old man with refractory atrial fibrillation is prescribed amiodarone.
Three months later, he reports increasing palpitations and diaphoresis. On
physical examination, his pulse rate is 90 beats/min and regular, his thyroid
gland is of normal size and is nontender, and he has a fine tremor
80
.
Which of the following would be the most specific indicator
of thyrotoxicosis in this patient?
A.
B.
C.
D.
E.
Elevated total T4 level
Elevated free T4 level
Suppressed serum TSH level
Low radioactive iodine uptake
Clinical signs and symptoms
Learning objective:
Identify the pattern of thyroid function test results in patients with amiodaroneinduced thyrotoxicosis.
81
Question 35: Adrenal Disorders
A 43-year-old woman is admitted to the hospital with polyphagia, a 40-lb (18.2kg) weight gain, and a 2-month history of generalized edema, weakness,
fatigue, dyspnea, and facial hirsutism. She also has a 6-month history of type 2
diabetes mellitus treated with a sulfonylurea.
On physical examination, her blood pressure is 150/96 mm Hg. Her height is 64
in (162.6 cm), and weight is 190 lb (86.4 kg) (BMI = 32.6 kg/m2). She has moon
facies, truncal obesity, and lanugo-type hair on the face. She has trace pretibial
edema. She has no striae, acne, or skin atrophy.
82
Laboratory test results:
8-AM plasma ACTH, undetectable
8-AM serum cortisol = 32.6 µg/dL (899.4 nmol/L) (reference range, 5-25 µg/dL
[137.9-689.7 nmol/L])
4-PM serum cortisol = 30.2 µg/dL (833.2 µg/dL) (reference range, 2-14 µg/dL
[55.2-386.2 nmol/L])
Urinary free cortisol = 399 µg/24 h (1101 nmol/d) (reference range, 4-50 µg/24
h [11-138 nmol/d])
CT of the abdomen is shown (see image).
83
Which of the following would be the most effective
treatment for this patient?
A.
B.
C.
D.
E.
Laparoscopic left adrenalectomy
Mitotane
Radiation therapy
Ketoconazole
Open laparotomy and left adrenalectomy
Learning objective:
Diagnose probable adrenocortical carcinoma on the basis of clinical
presentation and imaging phenotype on CT.
84
Question 36: Female Reproduction
A 17-year-old woman is referred to you for primary amenorrhea. The patient
had some breast development starting in the sixth grade, but her final breast
size is small. She grew slowly throughout her teen years and is now 1 inch
shorter than her predicted adult height. She has no galactorrhea, cold
intolerance, dizziness, or hot flashes.
On physical examination, her height is 64 in (162.6 cm), and weight is 127 lb
(57.6 kg) (BMI = 21.8 kg/m2). Her thyroid gland is normal on examination. Both
breast and pubic hair development is Tanner stage 4.
85
Laboratory test results:
Prolactin = 31.7 ng/mL (1.4 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30
nmol/L])
LH = 0.6 mIU/mL (reference range [prepubertal], <1.0 mIU/mL [<1.0 IU/L])
FSH = 4.4 mIU/mL (4.4 IU/L) (reference range [prepubertal], <3.0 mIU/mL [<3.0
IU/L])
Estradiol = <20 pg/mL (<73.4 pmol/L) (reference range [prepubertal], <20
pg/mL [<73.4 pmol/L])
86
Which of the following should you do next in this patient's
evaluation?
A.
B.
C.
D.
E.
Order pelvic ultrasonography
Measure total testosterone
Measure prolactin in a diluted serum sample
Order pituitary MRI
Order karyotype analysis
Learning objective:
Prioritize the workup of primary amenorrhea.
87
Question 37: Diabetes Mellitus and
Other Carbohydrate Disorders
A 39-year-old man is referred to you by a colleague in the psychiatry
department for evaluation of "metabolic syndrome."The patient has gained 26
lb (11.8 kg) over the past year and has developed hypertension and
dyslipidemia. His medical history is notable for schizophrenia/schizoaffective
disorder requiring treatment with olanzapine and trazodone, which he has
taken for the past 15 months. He also takes hydrochlorothiazide and a calcium
channel blocker for hypertension.
On physical examination, he has a flat affect, but is coherent and answers
questions appropriately. His blood pressure is 128/68 mm Hg. His height is 70
in (177.8 cm), and weight is 238 lb (108.2 kg) (BMI = 34.1 kg/m²). His waist
circumference is 41.3 in (105 cm). His skin has normal mobility and thickness,
he has central obesity, and his abdomen has pale striae. Muscle bulk and
strength are normal.
88
Laboratory test results (sample drawn while fasting):
TSH = 1.1 mU/L (reference range, 0.5-5.0 mIU/L)
Glucose = 119 mg/dL (6.6 mmol/L) (reference range, 70-99 mg/dL [3.9-5.5
mmol/L])
Total cholesterol = 224 mg/dL (5.80 mmol/L) (reference range [optimal], <200
mg/dL [<5.18 mmol/L])
Triglycerides = 427 mg/dL (4.83 mmol/L) (reference range [optimal], <150 mg/dL
[<3.88 mmol/L])
LDL cholesterol = 92 mg/dL (2.38 mmol/L) (reference range [optimal], <100
mg/dL [<2.59 mmol/L])
HDL cholesterol = 38 mg/dL (0.98 mmol/L) (reference range [optimal], >60
mg/dL [>1.55 mmol/L])
89
Which of the following is the best next step in this patient's
care?
A. Perform an overnight dexamethasone suppression test
B. Discuss alternative antipsychotic regimens with the patient's
psychiatrist
C. Initiate treatment with gemfibrozil
D. Initiate treatment with an HMG-CoA reductase inhibitor
E. Initiate treatment with metformin
Learning objective:
Recognize and manage the metabolic complications of atypical antipsychotic
medications.
90
Question 38: Bone and Mineral
Metabolism
A 55-year-old man comes to you for evaluation of recurrent kidney stones.
Twelve years ago he passed a stone of uncertain composition. Two months
ago, he passed a stone that was made of calcium oxalate.
His medical history is notable for sarcoidosis initially diagnosed 20 years ago
when he presented with bilateral hilar adenopathy and interstitial lung disease.
His pulmonary function and findings from chest x-rays have been stable, and
the hilar adenopathy has resolved.
He smoked 1 pack of cigarettes daily for 20 years, but has not smoked in the
last 20 years. He does not take vitamin D or calcium supplements and eats few
dairy products. He has had no fractures.
His physical examination findings are unremarkable.
91
Laboratory test results:
1,25-Dihydroxyvitamin D = 120 pg/mL (312 pmol/L) (reference range, 16-65
pg/mL [41.6-169.0 pmol/L])
25-Hydroxyvitamin D = 25 ng/mL (62.4 nmol/L) (reference range [optimal], 2580 ng/mL [62.4-199.7 nmol/L])
PTH = 10 pg/mL (10 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
TSH = 1.0 mIU/L (reference range, 0.5-5.0 mIU/L)
Albumin = 4.0 g/dL (40 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Calcium =10.6 mg/dL (2.7 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
Phosphorus = 4.4 mg/dL (1.4 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5
mmol/L])
Serum urea nitrogen = 20 mg/dL (7.1 mmol/L) (reference range, 8-23 mg/dL
[2.9-8.2 mmol/L])
Urinary calcium = 520 mg/24 h (13 mmol/d) (reference range, 100-300 mg/24 h
[2.5-7.5 mmol/d])
Urinary creatinine = 1.1 g/24 h (9.7 mmol/d) (reference range, 1.0-2.0 g/24 h
[8.8-17.7 mmol/d])
92
In addition to increasing his fluid intake, initiation of which
of the following should you recommend?
A.
B.
C.
D.
E.
A glucocorticoid
A thiazide
Nasal calcitonin
A low-oxalate diet
Potassium citrate supplementation
Learning objective:
Diagnose and treat granulomatous hypercalcemia and hypercalciuria.
93
Question 39: Lipids/Obesity
A 32-year-old woman had a peak lifetime BMI of 69 kg/m2. Nine weeks ago,
she had a laparoscopic gastric bypass procedure. After being discharged from
the hospital she did well for several weeks. However, for the last 3 weeks, she
has experienced frequent episodes of vomiting. Over the last week, she has
been vomiting almost everything that she eats. Over the last 2 days, her family
says that she has become increasingly confused and unsteady on her feet and
has complained of double vision. In the emergency department, she is found to
be confused, dysarthric, and unsteady on her feet. On neurologic examination,
she has a right third nerve palsy, nystagmus, and decreased sensation over her
lower extremities.
94
A deficiency of which of the following is most likely?
A.
B.
C.
D.
E.
Zinc
Vitamin D
Thiamine
Folate
Vitamin B12
Learning objective:
To be able to identify specific vitamin deficiencies that develop following
bariatric surgery.
95
Question 40: Bone and Mineral
Metabolism
A 63-year-old man who has had diabetes mellitus for 10 years is admitted to
the hospital with a history of severe itching of his legs for 1 and a half months
and painful ulcers on his right leg that have been present for 2 weeks. His
diabetes is complicated by peripheral neuropathy, gastroparesis, and chronic
renal insufficiency. Serum creatinine has been steadily increasing for the past 1
and a half years. He is awaiting the initiation of hemodialysis.
Over the past week, his leg pain has worsened and has been associated with
redness and swelling of his lower extremities, fever, chills, and rigors.
96
On physical examination, he appears quite ill. Blood pressure is 140/75 mm
Hg, pulse rate is 112 beats/min, respiratory rate is 14 breaths/min, and
temperature is 100.1°F (37.8°C). The oral mucosa is pink and dry. Findings
from cardiopulmonary examination are normal. There are multiple darkcolored, shallow ulcers on the anterior and lateral aspects of the distal third of
the right leg (see image). The bases of the lesions are firm to leathery in
consistency, and you observe surrounding erythema of the adjacent skin.
Pedal pulses are barely palpable bilaterally; there is good capillary refill.
Sensation to touch (monofilament) is reduced on the dorsal surface of both
feet.
97
Serum laboratory test results:
Sodium = 130 mEq/L (130 mmol/L) (reference range, 136-142 mEq/L [136-142
mmol/L])
Potassium = 4.9 mEq/L (4.9 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0
mmol/L])
Chloride = 90 mEq/L (90 mmol/L) (reference range, 96-106 mEq/L [96-106 mmol/L])
Bicarbonate = 18 mEq/L (18 mmol/L) (reference range, 21-28 mEq/L [21-28
mmol/L])
Serum urea nitrogen = 97 mg/dL (34.6 mmol/L) (reference range, 8-23 mg/dL [2.98.2 mmol/L])
Creatinine = 8.2 mg/dL (724.9 µmol/L) (reference range, 0.7-1.3 mg/dL [61.9-114.9
µmol/L])
Calcium = 8.3 mg/dL (2.1 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
Albumin = 2.9 g/dL (29 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Phosphorus = 8.5 mg/dL (2.7 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5
mmol/L])
PTH (intact) = 1130 pg/mL (1130 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
1,25-Dihydroxyvitamin D = <10 pg/mL (<26 pmol/L) (reference range, 16-65 pg/mL
[41.6-169.0 pmol/L])
98
Which of the following assessments is most likely to
confirm the presumptive diagnosis?
A.
B.
C.
D.
E.
Bone scan
Parathyroid sestamibi scan
Parathyroid ultrasonography
Skin biopsy
Plain x-ray of the lower extremities
Learning objective:
Confirm the suspected diagnosis of calciphylaxis in the setting of renal failure.
99
Question 41: Pituitary and
Neuroendocrine Disorders
A 68-year-old woman with hypertension (controlled on metoprolol) is referred to
you for a thyroid nodule. She does not have dysphagia, dyspnea, or
hoarseness.
Her blood pressure is 135/88 mm Hg, and her pulse rate is 68 beats/min. She
has frontal bossing, deep nasolabial folds, increased dental spacing, and a
prognathic jaw. There is a 1.5-cm, soft, nontender nodule palpable in the left
thyroid lobe. There is no cervical lymphadenopathy. Her hands and feet appear
enlarged and doughy.
100
Laboratory test results:
TSH = 0.7 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 1.3 ng/dL (16.7 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17
pmol/L])
IGF-1 = 1064 ng/mL (139.4 nmol/L) (reference range, 67-195 ng/mL [8.8-25.5
nmol/L])
Prolactin = 16 ng/mL (0.7 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30
nmol/L])
Liver function, normal
Brain MRI shows a mass on the left side of the sella involving the left
cavernous sinus (see image). There is aneurysmal dilatation of the left
intracavernous carotid artery. There is no pressure on the optic apparatus.
101
Two experienced pituitary neurosurgeons are consulted, but neither
recommends surgery. Octreotide LAR therapy is begun and is titrated to a
dosage of 30 mg every 4 weeks. She tolerates the medication well without
notable gastrointestinal adverse effects or hyperglycemia. On this dosage, her
serum IGF-1 concentration decreases to 654 ng/mL (85.7 nmol/L). A follow-up
brain MRI shows no change in tumor size.
102
Which of the following is the best management step now?
A.
B.
C.
D.
E.
Switch to lanreotide depot
Switch to pegvisomant
Add cabergoline
Add pegvisomant
Add bromocriptine
Learning objective:
Recommend combination medical therapy (somatostatin analogue plus
pegvisomant) in selected patients with acromegaly.
103
Question 42: Diabetes Mellitus and
Other Carbohydrate Disorders
A 31-year-old man with a 20-year history of type 1 diabetes mellitus has been on
insulin pump therapy for more than 5 years. He presents for follow-up and help with
recurrent mild hypoglycemia. He reports having mild hypoglycemic episodes many
afternoons, which occur at least 4 hours after lunch and are characterized by sweating
and anxiety. During these episodes, self-monitored blood glucose values are between
50 and 60 mg/dL (2.8 and 3.3 mmol/L). You examine his log book and see documented
hypoglycemic values between 50 and 64 mg/dL (2.8 and 3.6 mmol/L), approximately 4
times per week at 5 PM.
The patient uses insulin aspart in his pump. Current pump settings:
Basal rates:
Midnight to 6 AM: 0.7 units/h
6 AM to midnight: 1.0 units/h
Correction (sensitivity) factor: 1 unit/40 mg glucose
Insulin-to-carbohydrate ratio: 1 unit:15 g
His height is 71 in (180.3 cm), and weight is 187 lb (85 kg) (BMI = 26.1 kg/m2).
104
Which of the following is the best advice now to alleviate
his hypoglycemic episodes?
A.
B.
C.
D.
E.
Increase his carbohydrate intake at lunch
Have a carbohydrate snack at 3 or 4 PM
Change the prelunch carbohydrate ratio to 1:10
Change the prelunch carbohydrate ratio to 1:20
Perform a check of the basal rate from breakfast until dinner
Learning objective:
Devise a strategy to identify and correct a common problem encountered with
the use of continuous subcutaneous insulin infusion.
105
Question 43: Adrenal Disorders
You are asked to evaluate a 16-year-old adolescent for adrenal insufficiency.
He has a 2-year history of attention deficit disorder, for which he is currently
treated with methylphenidate. He has had a rapid onset of neurologic
symptoms, including weakness in his lower extremities, gait instability, slurred
speech, and confusion. On physical examination, he has hyperpigmentation in
sun-exposed areas, brisk deep tendon reflexes, clonus in the left ankle, and
bilateral Babinski sign. There is no family history of any endocrine disorders.
Pituitary-adrenal function testing documents a morning basal plasma ACTH
concentration of 144 pg/mL (31.7 pmol/L) (reference range, 10-60 pg/mL [2.213.2 pmol/L]) and a serum cortisol concentration of 3.7 µg/dL (102.1 nmol/L)
(reference range, 5-25 µg/dL [13.7.9-689.7 nmol/L]). There is no further
increase in cortisol after administration of 250 mcg of intravenous cosyntropin.
106
Which of the following should you recommend to identify
the most likely cause of adrenal insufficiency in this
patient?
A.
B.
C.
D.
E.
Measure very-long-chain fatty acids
Measure 21-hydroxylase antibodies
Measure lupus anticoagulant
Perform CT of the adrenal glands
Discontinue methylphenidate and repeat pituitary-adrenal testing
Learning objective:
Include adrenoleukodystrophy in the differential diagnosis of any young male
patient with primary adrenal insufficiency of unknown cause, especially in the
presence of concomitant neurologic symptoms.
107
Question 44: Bone and Mineral
Metabolism
A 79-year-old woman recently began treatment with zoledronic acid, 5 mg
intravenously, for osteoporosis documented by DXA. Several days after
receiving the medication, she experienced intermittent severe cramps in her
hands and legs, as well as some tightening in her throat.
Her medical history includes a total thyroidectomy for a large goiter when she
was a teenager. She also has a history of rare, grand mal seizures well
controlled with anticonvulsant agents. Current medications include
levothyroxine and phenobarbital.
On physical examination, Chvostek and Trousseau signs are present.
Electrocardiography shows that the QTc interval is prolonged to 0.51 seconds.
108
Laboratory test results:
Calcium = 6.5 mg/dL (1.6 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
Phosphorus = 6.5 mg/dL (2.1 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5
mmol/L])
Magnesium = 2.0 mg/dL (0.8 mmol/L) (reference range, 1.5-2.3 mg/dL [0.6-0.9
mmol/L])
PTH = 15 pg/mL (15 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
Serum urea nitrogen = 6 mg/dL (2.1 mmol/L) (reference range, 8-23 mg/dL
[2.9-8.2 mmol/L])
Creatinine = 0.6 mg/dL (53.0 µmol/L) (reference range, 0.6-1.1 mg/dL [53.097.2 µmol/L])
TSH = 8.3 mIU/L (reference range, 0.5-5.0 mIU/L)
Electrolytes, normal
109
Which of the following is the most likely cause of this
patient's hypocalcemia?
A.
B.
C.
D.
E.
Hypothyroidism
Vitamin D deficiency
Hypomagnesemia
Phenobarbital
Hypoparathyroidism
Learning objective:
Identify hypoparathyroidism after thyroid surgery as the cause of hypocalcemia.
110
Question 45: Female Reproduction
A 16-year-old girl presents with primary amenorrhea. She underwent thelarche
at age 10 years, but had no axillary or pubic hair development. She has had no
hot flashes, acne, hirsutism, galactorrhea, or symptoms of thyroid disease, and
she is not sexually active.
On physical examination, her blood pressure is 110/80 mm Hg. Her height is 69
in (175.3 cm), and weight is 147 lb (66.8 kg) (BMI = 21.7 kg/m2). On skin
examination, she has no axillary or pubic hair. Her breasts are Tanner stage 4.
Pelvic examination reveals a vaginal length of 1.5 cm. A mass is palpated in the
right inguinal area.
111
Laboratory test results:
Prolactin = 8.6 ng/mL (0.37 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30
nmol/L])
FSH = 3.2 mIU/mL (3.2 IU/L) (reference range [prepubertal], <3.0 mIU/mL [<3.0
IU/L])
LH = 15.0 mIU/mL (15.0 IU/L) (reference range [prepubertal], <1.0 mIU/mL
[<1.0 IU/L])
Testosterone = 390 ng/dL (13.5 nmol/L) (reference range, 8-60 ng/dL [0.3-2.1
nmol/L])
Estradiol = 45 pg/mL (165.2 pmol/L) (reference range [prepubertal], <20 pg/mL
[<73.4 pmol/L])
β-hCG = <3.0 mIU/mL (<3.0 IU/L) (reference range, <3.0 mIU/mL [<3.0 IU/L])
112
Which of the following is the best therapeutic option now?
A.
B.
C.
D.
E.
Estradiol
Gonadectomy
Low-dosage oral contraceptive
Spironolactone
Estradiol and progesterone
Learning objective:
Recommend treatment for a woman with complete androgen insensitivity
syndrome.
113
Question 46: Bone and Mineral
Metabolism
A 63-year-old woman presented 5 years ago with a calcium concentration of
11.8 mg/dL (3.0 mmol/L) and a PTH concentration of 259 pg/mL (259 ng/L). A
sestamibi imaging study was positive for uptake in the left neck.
Parathyroidectomy was performed with an appropriate drop in intraoperative
intact PTH levels and normalization of serum calcium to 9.4 mg/dL (2.4
mmol/L). Her calcium level remained normal until 4 months ago, when it was
documented to be 10.6 mg/dL (2.7 mmol/L).
She reports no confusion or fatigue, constipation, kidney stones, or history of
fractures. She has a history of hypertension and takes amlodipine. Her family
history is unremarkable.
Physical examination findings are unremarkable.
114
Laboratory test results:
Albumin = 4.4 g/dL (44 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Calcium = 10.7 mg/dL (2.7 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L])
Creatinine = 0.9 mg/dL (79.6 µmol/L) (reference range, 0.6-1.1 mg/dL [53.0-97.2 µmol/L])
Phosphorus = 1.7 mg/dL (0.5 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5 mmol/L])
PTH = 95 pg/mL (95 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
25-Hydroxyvitamin D = 27 ng/mL (67.4 nmol/L) (reference range [optimal], 25-80 ng/mL
[62.4-199.7 nmol/L])
24-Hour urinary measurements:
Volume = 2600 mL/24 h
Creatinine = 0.9 g/24 h (7.9 mmol/d) (reference range, 1.0-2.0 g/24 h [8.8-17.7 mmol/d])
Calcium = 294 mg/24 h (7.4 mmol/d) (reference range, 100-300 mg/24 h [2.5-7.5
mmol/d])
Bone mineral density measurement reveals low bone density (osteopenia) with the
lowest T score at the femoral neck of -1.9.
115
Which of the following should be the next management
step?
A.
B.
C.
D.
E.
Initiation of bisphosphonate treatment
Initiation of cinacalcet treatment
Initiation of estrogen treatment
Neck exploration
Observation with serum calcium monitoring
Learning objective:
Use the guidelines for surgery to determine care of patients with asymptomatic
primary hyperparathyroidism.
116
Question 47: Male Reproduction
A 62-year-old man with a 10-year history of type 2 diabetes mellitus seeks help
for erectile dysfunction. He reports a normal libido. He jogs 2 miles in about 25
minutes 3 times a week and has no chest pain or claudication. Other than the
erectile dysfunction, he feels well and has no other concerns. His medical
history includes hypertension and dyslipidemia. Current medications are
ramipril, 10 mg daily; atorvastatin, 40 mg daily; and metformin, 2000 mg daily.
On physical examination, his blood pressure is 128/72 mm Hg and heart rate is
68 beats/min. His height is 68 in (172.7 cm), and weight is 185 lb (84.1 kg)
(BMI = 28.1 kg/m2) He is well virilized. Findings on cardiopulmonary and
abdominal examinations are normal. He has 20-mL testes bilaterally.
117
Laboratory test results:
Total testosterone = 280 ng/dL (9.7 nmol/L) (reference range, 300-900 ng/dL
[10.4-31.2 nmol/L])
Fasting lipid panel
Total cholesterol = 215 mg/dL (5.57 nmol/L) (reference range [optimal], <200
mg/dL [<5.18 mmol/L])
HDL cholesterol = 35 mg/dL (0.91 nmol/L) (reference range [optimal], >60
mg/dL [>1.55 mmol/L])
LDL cholesterol = 115 mg/dL (2.98 nmol/L) (reference range [optimal], <100
mg/dL [<2.59 mmol/L])
Triglycerides = 200 mg/dL (2.26 nmol/L) (reference range [optimal], <150
mg/dL [<3.88 mmol/L])
Hemoglobin A1c = 7.2% (55 mmol/mol) (reference range, 4.0%-5.6% [20-38
mmol/mol])
118
Which of the following is the best next step before initiating
therapy for the management of his erectile dysfunction?
A.
B.
C.
D.
E.
Measurement of free testosterone
Exercise tolerance test
Measurement of lipoprotein(a)
Measurement of prostate-specific antigen
No further testing needed; initiate trial of an oral phosphodiesterase
inhibitor
Learning objective:
Determine whether a patient needs formal cardiovascular assessment before
starting an oral phosphodiesterase inhibitor for erectile dysfunction.
119
Question 48: Diabetes Mellitus and
Other Carbohydrate Disorders
A 70-year-old woman with a 10-year history of type 2 diabetes mellitus presents
for her usual follow-up appointment. She has taken glyburide for 7 years, but
began to require additional therapy 3 years ago. She did not tolerate metformin
and had no response to rosiglitazone; thus, insulin was added to her regimen.
Initially, her condition was well controlled with a combination of glyburide and
bedtime NPH insulin. Over the past 18 months, glyburide was stopped, and she
has required a twice-daily dose of both NPH and regular insulin, given before
breakfast and dinner. Over the past 6 months, despite an increased insulin
dosage, her hemoglobin A1c level has increased to 9.0% (75 mmol/mol)
(reference range, 4.0%-5.6% [20-38 mmol/mol]). Nevertheless, while taking this
higher insulin dosage, she has developed hypoglycemia both before lunch and
during the night.
120
Which of the following is the best solution to her problem?
A. Move the before-dinner NPH insulin to bedtime; no other change in the
insulin regimen
B. Move the before-dinner NPH insulin to bedtime; stop all regular insulin
doses
C. Replace the twice-daily regular insulin with a rapid-acting insulin analogue;
no change in NPH insulin
D. Replace the twice-daily regular insulin with a rapid-acting insulin
analogue; reduce the morning rapid-acting analogue dosage slightly;
increase the morning NPH insulin dose; move the before-dinner NPH
insulin to bedtime
E. Replace the twice-daily NPH insulin with a single daily dose of insulin
glargine; stop all regular insulin doses
Learning objective:
Improve insulin regimens when there is concomitant high hemoglobin A1c
levels and recurrent hypoglycemia.
121
Question 49:Lipids/Obesity
A 13-year-old boy is referred to you for evaluation of severe obesity, short
stature, mild mental retardation, delayed sexual maturation, and behavioral
problems. At birth, he had hypotonia and poor feeding and failed to gain weight
normally. Between the ages of 4 and 6 years, he continued to have hypotonia
and short stature and began gaining weight rapidly. Between the ages of 6 and
13 years, he had dramatic weight gain due to ravenous hunger. He did poorly in
school and was placed in special education. There is no family history of
severe obesity. On physical examination, his height is 53 in (134.6 cm) and
weight is 280 lb (127.3 kg) (BMI = 70.1 kg/m2). He appears prepubertal on
examination. Testes are not palpable.
122
Although a number of issues must be addressed, replacing
or supplementing which of the following hormones is most
likely to improve his body composition and overall health?
A.
B.
C.
D.
E.
Thyroid hormone
Leptin
Growth hormone
Testosterone
Hydrocortisone
Learning objective:
To understand the benefits of providing growth hormone supplementation to
children with Prader-Willi syndrome.
123
Question 50: Female Reproduction
A 51-year-old healthy woman presents with recent onset of severe hot flashes
and insomnia. She had normal menarche and had regular menses until her late
40s. At age 50 years, an evaluation for irregular menses identified leiomyomata
requiring total abdominal hysterectomy and oophorectomy. The operation was
performed 4 months ago. Since her surgery, she has had intractable hot
flashes, trouble sleeping, cognitive issues, and urinary frequency.
Her grandmother had breast cancer at age 78 years, her father has
hypertension and hyperlipidemia, and her mother has osteoporosis. The patient
runs 3 times a week and adheres to a healthful diet and lifestyle. She does not
drink alcohol and has no history of angina or claudication.
On physical examination, her height is 66 in (167.6 cm) and weight is 124 lb
(56.4 kg) (BMI = 20 kg/m2). Blood pressure is 110/60 mm Hg. The rest of her
physical examination findings are normal.
124
Results of laboratory studies are normal, including a lipid
panel:
Total Cholesterol = 138 mg/dL (3.57 mmol/L) (reference range [optimal], <200
mg/dL [5.18 mmol/L])
HDL cholesterol = 61 mg/dL (1.58 mmol/L) (reference range [optimal], >60
mg/dL [>1.55 nmol/L])
LDL cholesterol = 59 mg/dL (1.53 mmol/L) (reference range [optimal], <100
mg/dL [<2.59 mmol/L])
Triglycerides = 88 mg/dL (0.99 mmol/L) (reference range [optimal], <150 mg/dL
[<3.88 mmol/L])
125
On the basis of this patient's history and physical
examination, for which of the following complications would
she be at increased risk after initiation of estradiol therapy?
A.
B.
C.
D.
E.
Myocardial infarction
Breast cancer
Stroke
Pancreatitis
Colon cancer
Learning objective:
Discuss the pros and cons of physiologic HT at the menopause.
126
Question 51: Diabetes Mellitus and
Other Carbohydrate Disorders
A 48-year-old, morbidly obese woman with an 8-year history of type 2 diabetes
mellitus comes to you seeking a second opinion. She states that her diabetes has
never been well controlled; however, she admits that she has never been
completely adherent to the diet and exercise plan that her physician prescribed.
She has been taking a sulfonylurea and metformin for the past 5 years, and she
mentions that her hemoglobin A1c level has always been close to 8.0% (64
mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol]).
Her medical history is notable for longstanding hypertension and hyperlipidemia.
She has had stable renal function for the past 3 years with a serum creatinine level
of 1.4 mg/dL (123.8 µmol/L) (reference range, 0.6-1.1 mg/dL [53.0-97.2 µmol/L])
and a creatinine clearance of 75 mL/min (reference range, 90-140 mL/min).
Findings from her physical examination are most notable for obesity (BMI = 40
kg/m2), but she has no obvious physical signs of diabetic retinopathy or neuropathy.
127
In discussing whether a dipeptidyl-peptidase 4 inhibitor is a
potential therapeutic option, which of the following should
you tell this patient?
A. She can expect to experience severe nausea and/or vomiting
B. Patients who use these medications lose, on average, 10 lb (4.5 kg),
whether or not they experience any gastrointestinal adverse effects
C. She will be able to use these medications even though her renal
function is not entirely normal
D. She would be unlikely to experience any significant improvement in
glycemic control
E. There is no risk of hypoglycemia if she adds this medication to her present
regimen
Learning objective:
Prescribe dipeptidyl-peptidase 4 inhibitors in the treatment of type 2 diabetes
mellitus.
128
Question 52:Bone and Mineral
Metabolism
You are asked to see a 73-year-old postmenopausal woman for osteoporosis
with previous vertebral compression fractures. Assessment of bone mineral
density reveals a T score of -2.6 at the hip. She has a history of diabetes
mellitus. Chronic kidney disease has been diagnosed, and she will need
hemodialysis in the future. She also has a history of anemia, hyperlipidemia,
and hypothyroidism treated with levothyroxine.
129
Laboratory tests results:
Creatinine = 2.8 mg/dL (247.5 µmol/L) (reference range, 0.6-1.1 mg/dL [53.097.2 µmol/L]) (glomerular filtration rate = 20.4 mL/min)
Calcium = 8.6 mg/dL (2.2 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
Albumin = 3.6 g/dL (36 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Phosphorus = 4.0 mg/dL (1.3 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5
mmol/L])
Alkaline phosphatase = 172 U/L (2.9 µkat/L) (reference range, 50-120 U/L
[0.84-2.00 µkat/L])
PTH = 648 pg/mL (648 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
25-Hydroxyvitamin D = 7 ng/mL (17.5 nmol/L) (reference range [optimal], 25-80
ng/mL [62.4-199.7 nmol/L])
1,25-Dihydroxyvitamin D = 7 pg/mL (18.2 pmol/L) (reference range, 16-65
pg/mL [41.6-169.0 pmol/L])
TSH = 1.1 mIU/L (reference range, 0.5-5.0 mIU/L)
130
Which of the following medications should you prescribe?
A.
B.
C.
D.
E.
Alendronate
Cinacalcet
Calcitriol
Raloxifene
Ergocalciferol
Learning objective:
Plan the treatment of osteoporosis in a patient with chronic kidney disease.
131
Question 53:Pituitary and
Neuroendocrine Disorders
A 31-year-old woman with a history of prolactinoma is now in her 37th week of
pregnancy. Two years ago, a 14-mm prolactinoma was identified. Her initial
prolactin level was 320 ng/mL (13.9 nmol/L) (reference range, 4-30 ng/mL
[0.17-1.30 nmol/L]), and there was suprasellar extension on MRI, chiasmal
compression, and a small visual field defect. With cabergoline, 0.5 mg twice
weekly, her prolactin normalized, her galactorrhea and amenorrhea resolved,
her visual field normalized, and her tumor decreased in size to 5 mm. She
stopped cabergoline when she learned she was pregnant. She now reports
increasing headaches that are quite severe. Goldmann visual field testing is
normal.
132
Which of the following is the best next step in her
management?
A.
B.
C.
D.
E.
Measure serum prolactin
Deliver the baby
Proceed with transsphenoidal surgical tumor removal
Perform a pituitary-directed MRI
Perform a pituitary-directed CT
Learning objective:
Manage prolactinoma during pregnancy.
133
Question 54: Diabetes Mellitus and
Other Carbohydrate Disorders
A 31-year-old woman presents for routine follow-up of type 1 diabetes mellitus of 18
years duration. She has maintained good control of her glucose with hemoglobin
A1c values less than 7.2% (<55 mmol/mol) for the last 10 years. She has mild,
nonproliferative retinopathy, but no other chronic complications. For the last 1 to 2 years,
she has reported some loss of hypoglycemic recognition and has experienced at least 1
severe hypoglycemic episode requiring assistance after a day of high physical activity.
Medications include insulin glargine, 15 units in the morning, and insulin lispro, 1 unit per
18 g of carbohydrate and 1 unit per 50 mg/dL (2.8 mmol/L) correction with a premeal
blood glucose target of 120 mg/dL (6.7 mmol/L).
Her blood pressure is 116/71 mm Hg, and pulse rate is 68 beats/min. Her height is 64 in
(162.6 cm), and weight is 126 lb (57.3 kg) (BMI = 21.6 kg/m2). Physical examination
findings are normal other than scattered microaneurysms on an undilated funduscopic
examination.
134
Laboratory test results:
Creatinine = 0.7 mg/dL (61.9 µmol/L) (reference range, 0.6-1.1 mg/dL [53.097.2 µmol/L])
Potassium = 4.1 mEq/L (4.1 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0
mmol/L])
Sodium = 138 mEq/L (138 mmol/L) (reference range, 136-142 mEq/L [136-142
mmol/L])
LDL cholesterol = 73 mg/dL (1.89 mmol/L) (reference range [optimal], <100
mg/dL [<2.59 mmol/L])
Hemoglobin A1c = 6.6% (49 mmol/mol) (reference range, 4.0%-5.6% [20-38
mmol/mol])
Albumin to creatinine ratio = 11 µg/mg creatinine
135
The following are the most recent blood glucose readings from her meter
download and are similar to the glucose values that were downloaded from
the last month.
Glucose Concentration
Day of Week
Wednesday
Thursday
Friday
Saturday
Sunday
136
Breakfast
Lunch
Dinner
Bedtime
60 mg/dL
254 mg/dL
133 mg/dL
102 mg/dL
(3.3 mmol/L)
(14.1 mmol/L)
(7.4 mmol/L)
(5.7 mmol/L)
317 mg/dL
211 mg/dL
175 mg/dL
121 mg/dL
(17.6 mmol/L)
(11.7 mmol/L)
(9.7 mmol/L)
(6.7 mmol/L)
276 mg/dL
202 mg/dL
113 mg/dL
95 mg/dL
(15.3. mmol/L)
(11.2 mmol/L)
(6.3 mmol/L)
(5.3 mmol/L)
83 mg/dL
132 mg/dL
87 mg/dL
170 mg/dL
(4.6 mmol/L)
(7.3 mmol/L)
(4.8 mmol/L)
(9.4 mmol/L)
62 mg/dL
262 mg/dL
142 mg/dL
123 mg/dL
(3.4 mmol/L)
(14.5 mmol/L)
(7.9 mmol/L)
(6.8 mmol/L)
Which of the following actions is most appropriate now?
A.
B.
C.
D.
E.
Perform a continuous glucose monitoring study
Change the carbohydrate counting ratio to 1:12 g carbohydrate at breakfast
Increase the insulin glargine dosage to 17 units
Recommend no intervention because her blood glucose is well controlled
Change the insulin glargine timing from morning to evening without
alteration of meal dosing
Learning objective:
Describe the utility of continuous glucose monitoring in confirming nocturnal
hypoglycemia.
137
Question 55: Adrenal Disorders
A 63-year-old man presents with a 3-month history of diarrhea and facial flushing. One
year ago, he underwent surgery to remove a rectal mass that was confirmed to be a
carcinoid tumor by histopathologic evaluation. Abdominal CT performed immediately after
his operation was reportedly normal.
On physical examination, he has facial plethora. His blood pressure is 128/78 mm Hg.
His concentration of urinary 5-hydroxyindoleacetic acid is 125 mg/24 h (654 µmol/d)
(reference range, 2-9 mg/24 h [10.5-47.1 µmol/d]). Abdominal MRI (see image) shows
multiple hypodense liver lesions (largest measuring 6 cm), enlarged para-aortic lymph
nodes, and peritoneal nodules. All findings are consistent with metastatic carcinoid. No
octreotide-avid lesion is identified on 111In-octreotide scan.
138
Which of the following is the most appropriate next step in
managing this patient's symptoms?
A.
B.
C.
D.
E.
Octreotide therapy
Liver transplant
Sunitinib therapy
Radiofrequency ablation of liver metastases
Interferon-α therapy
Learning objective:
Recommend a trial of somatostatin analogue therapy for symptomatic relief in
the setting of metastatic carcinoid syndrome, even if the disease is not
octreotide avid.
139
Question 56: Lipids/Obesity
You are referred a 48-year-old man with a 12-year history of coronary artery
disease and multiple hospitalizations for coronary artery stent placements. The
patient's family has a strong history of heart disease: his father and 2 paternal
uncles died before age 50 years. The patient takes atorvastatin, 80 mg daily.
Laboratory test results (on his current statin):
Total cholesterol = 210 mg/dL (5.44 mmol/L) (reference range [optimal], <200
mg/dL [<5.18 mmol/L])
LDL cholesterol = 150 mg/dL (3.89 mmol/L) (reference range [optimal], <100
mg/dL [<2.59 mmol/L])
HDL cholesterol = 40 mg/dL (1.04 mmol/L) (reference range [optimal], >60
mg/dL [>1.55 mmol/L])
Triglycerides = 100 mg/dL (1.13 mmol/L) (reference range [optimal], <150
mg/dL [<3.88 mmol/L])
140
Which of the following are you most likely to find on
physical examination?
A.
B.
C.
D.
E.
Lipemia retinalis
Achilles xanthomas
Eruptive xanthomas
Palmar xanthomas
Arthropathy
Learning objective:
Identify physical findings of hyperlipidemias.
141
Question 57: Bone and Mineral
Metabolism
A 42-year-old woman is referred to you for assistance in the management of
hypercalcemia. Six months ago, screening laboratory testing revealed a calcium
concentration of 11.1 mg/dL (2.78 mmol/L) and a normal creatinine concentration of 0.7
mg/dL (61.9 µmol/L). Six weeks ago, the patient returned for further laboratory tests
when she had a positive home pregnancy test:
Calcium = 10.8 mg/dL (2.7 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L])
Albumin = 4.0 g/dL (40 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Alkaline phosphatase = 42 U/L (0.70 µkat/L) (reference range, 50-120 U/L [0.84-2.00
µkat/L])
PTH = 95.7 pg/mL (95.7 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
25-Hydroxyvitamin D = 28 ng/mL (69.89 nmol/L) (reference range [optimal], 25-80 ng/mL
[62.4-199.7 nmol/L])
1,25-Dihydroxyvitamin D = 84 pg/mL (218.4 pmol/L) (reference range, 16-65 pg/mL [41.6169.0 pmol/L])
Urinary calcium = 281 mg/24 h (7.02 mmol/d) (reference range, 100-300 mg/24 h [2.5-7.5
mmol/d])
142
She is now 10 weeks pregnant. Physical examination findings are normal,
including those from head and neck exam. You learn that her mother had
hyperparathyroidism diagnosed at age 60 years. You discuss with the patient
her condition and its implications for the current pregnancy. She is reluctant to
do anything regarding her hypercalcemia out of concern for the fetus.
The pregnancy progresses normally and the patient's calcium concentration
remains between 10.7 mg/dL and 11.3 mg/dL (2.7-2.8 mmol/L). The baby is
delivered vaginally at 40 weeks' gestation.
143
Which of the following represents the most likely immediate
postpartum complication for the baby?
A.
B.
C.
D.
E.
Hypercalcemia
Hypocalcemia
Fracture
Nephrocalcinosis
Renal malformation
Learning objective:
Counsel patients on the risk of maternal primary hyperparathyroidism to the
developing fetus and newborn and review the physiology of calcium
homeostasis in pregnancy.
144
Question 58:Pituitary and
Neuroendocrine Disorders
A 42-year-old man is referred to you for further evaluation of possible Cushing
syndrome. The patient has been generally healthy, and he fathered 2 children
(4 and 8 years ago). However, over the past 2 years, he has gained about 25 lb
(11.3 kg), mostly around his abdomen, despite dieting and exercising. He
visited his primary care physician last month. The physician noted that he had
new-onset hypertension and was concerned about his physical changes. He
sent off laboratory tests and ordered a pituitary MRI; when these results
returned, he referred the patient to you.
On physical examination, the patient's blood pressure is 140/92 mm Hg. He
has a small dorsocervical fat pad, acne, a ruddy complexion, a protuberant
abdomen, and proximal muscle weakness in his lower extremities.
145
Laboratory test results:
Plasma ACTH = 86 pg/mL (18.9 pmol/L) (reference range, 10-60 pg/mL [2.213.2 pmol/L])
Serum cortisol (8 AM) = 18 µg/dL (496.6 nmol/L) (reference range, 5-25 µg/dL
[137.9-689.7 nmol/L])
Serum cortisol (8 AM) after 8 mg of dexamethasone the night before = 10 µg/dL
(reference range, >50% reduction in cortisol)
Urinary free cortisol = 360 μg/24 h (993.6 nmol/d) (reference range, 4-50 µg/24
h [11-138 nmol/d])
Potassium = 2.8 mEq/L (2.8 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0
mmol/L])
MRI of the pituitary demonstrates a 4-mm lesion on the right side of the
pituitary that is hypoenhancing after gadolinium contrast administration.
14
6
Which of the following should be performed next?
A. Bilateral adrenal venous sampling
B. Inferior petrosal sinus sampling
C. Corticotropin-releasing hormone stimulation test after dexamethasone
suppression
D. Midnight salivary free cortisol measurements
E. No further testing is needed; proceed to transsphenoidal resection of the
pituitary lesion
Learning objective:
Select the appropriate tests for the differential diagnosis of Cushing syndrome.
147
Question 59: Diabetes Mellitus and
Other Carbohydrate Disorders
You are asked to see a 19-year-old college student with newly recognized
diabetes mellitus that was identified through the use of a home glucose meter
belonging to her father who has type 1 diabetes mellitus.
On physical examination, her height is 65 in (165.1 cm) and weight is 158 lb
(71.8 kg) (BMI = 26.3 kg/m2). Her blood pressure is 106/67 mm Hg, and pulse
rate is 62 beats/min. All findings from your examination are normal, and,
specifically, there are no skin or thyroid abnormalities.
Islet-cell antibodies, insulin autoantibodies, and glutamic acid decarboxylase
antibodies are absent.
148
Which of the following tests, if available to you, could be
useful in confirming type 1 diabetes in this patient?
A. Zinc transporter (ZnT8) antibody testing
B. Genetic testing for maturity onset diabetes of the young (DNA sequencing
of HNF4A and HNF1A)
C. HLA genotyping
D. Transcription factor 7-like 2 (TCF7L2) genetic testing
E. Intravenous glucose tolerance testing
Learning objective:
Incorporate autoantibody testing in the diagnosis of type 1 diabetes mellitus.
149
Question 60: Bone and Mineral
Metabolism
You are asked to evaluate a 57-year-old woman after she sustained 2 vertebral
compression fractures. Two months ago, she was stepping off a curb and fell. She
experienced immediate, sharp pain in her mid and lower back. Radiographs revealed T11
and L3 compression fractures. She was treated with bed rest and analgesics without
improvement. She underwent vertebroplasty 3 weeks after the initial event and her pain
improved immediately.
Menopause occurred at age 52 years. She does not smoke cigarettes and has never
been on glucocorticoid therapy. Her mother sustained a hip fracture at age 84 years. The
patient takes 500 mg of elemental calcium and 1000 IU of vitamin D3 daily. There is no
history of nephrolithiasis.
Physical examination findings are normal, aside from modest discomfort with palpation
over the 2 involved vertebral bodies. There is no evidence of thyroid disease or
hypercortisolism. Results from a thorough laboratory investigation for causes of bone loss
(including a chemistry panel, serum and urine protein electrophoresis, thyroid function
tests, and vitamin D levels) are normal.
150
You order a DXA scan with vertebral morphometric analysis, and the results are shown:
Spine morphometry
On the basis of these findings, you discuss the importance of treating her
osteoporosis and commence therapy with alendronate, 70 mg weekly.
151
Which of the following adverse events is most likely within
the coming year?
A.
B.
C.
D.
E.
Additional vertebral fracture
Femoral neck fracture
Subtrochanteric femoral fracture
Osteonecrosis of the jaw
Nephrolithiasis
Learning objective:
Assess risk of future adverse events in a patient after fragility fracture and
subsequent treatment.
152
Question 61:Lipids/Obesity
A 28-year-old man presents to the emergency department with crushing chest pain and is
found to have a myocardial infarction. He does not smoke cigarettes, and until this event he
was healthy and taking no medications. He is adopted, so no family history is available.
On physical examination, he appears well. His height is 72 in (182.9 cm), and weight is 210 lb
(95.5 kg) (BMI = 28.5 kg/m2). After a careful physical examination, the only abnormalities you
identify are thickening of his Achilles tendons bilaterally and xanthelasmas.
Fasting laboratory test results:
Total cholesterol = 405 mg/dL (10.49 mmol/L) (reference range [optimal], <200 mg/dL
[<5.18 mmol/L])
HDL cholesterol = 52 mg/dL (1.35 mmol/L) (reference range [optimal], >60 mg/dL [>1.55
mmol/L])
LDL cholesterol = 336 mg/dL (8.70 mmol/L) (reference range [optimal], <100 mg/dL
[<2.59 mmol/L])
Triglycerides = 85 mg/dL (0.96 mmol/L) (reference range [optimal], <150 mg/dL [<3.88
mmol/L])
153
A mutation in the gene encoding which of the following is
the most likely cause of his dyslipidemia?
A.
B.
C.
D.
E.
LDL receptor
Lipoprotein lipase
Apolipoprotein E
Apolipoprotein CII
Lipoprotein (a)
Learning objective:
Differentiate among the genetic syndromes that cause elevated LDL
cholesterol.
154
Question 62:Diabetes Mellitus and
Other Carbohydrate Disorders
An 18-year-old man presents to the endocrinology clinic with symptoms of polyuria
and polydipsia, as well as home glucose monitoring results documenting
hyperglycemia. Eight years ago, his mother started monitoring his blood glucose
levels using an over-the-counter blood glucose monitor. For the last several years,
fasting blood glucose values were above 100 mg/dL (>5.6 mmol/L), and
postprandial blood glucose values were below 140 mg/dL (<7.8 mmol/L). Screening
for type 1 diabetes mellitus (C-peptide and islet-cell antibodies) was negative when
performed at an initial visit at age 10 years. Results from initial glucose tolerance
testing were also normal. Subsequently, the patient developed mild hyperglycemia
that was treated with very low-dosage basal insulin. He has continued this
treatment and now presents for his appointment wanting to know whether to
continue the insulin and what to expect regarding his long-term glycemic control.
155
In asking about his family history, you learn that his maternal aunt, 2 maternal
uncles, and maternal grandmother have type 2 diabetes.
On physical examination, his height is 69.5 in (176.5 cm) and weight is 110 lb (50
kg) (BMI = 16 kg/m2). His pulse rate is 76 beats/min, and blood pressure is 106/74
mm Hg. His thyroid gland is normal without nodularity, and his skin does not have
hyperpigmentation or acanthosis nigricans. He has no symptoms of peripheral
neuropathy, vision changes, or other diabetes-associated complications. The rest of
the examination findings are normal.
156
Which of the following assessments would best categorize
his type of diabetes?
A.
B.
C.
D.
E.
Test for islet-cell antibodies and insulin autoantibodies
Order genetic testing for mutations in the glucokinase gene (GCK)
Perform a 75-g oral glucose tolerance test
Measure glutamic acid decarboxylase antibodies
Measure zinc transporter (ZnT8) autoantibodies
Learning objective:
Suspect maturity-onset diabetes of the young in a patient with an atypical
clinical course.
157
Question 63:Male Reproduction
A 72-year-old man in whom secondary hypogonadism was recently diagnosed presents to
the endocrine clinic for initiation of testosterone therapy. His medical history includes
hypertension, mild benign prostatic hypertrophy, and coronary artery disease (for which he
underwent angioplasty 7 years ago). He has no symptoms from his medical conditions,
with no complaints of hesitancy, change in urinary stream, angina, or claudication. His
hypertension is controlled with hydrochlorothiazide, 50 mg daily.
On physical examination, his height is 70 in (177.8 cm) and weight is 190 lb (86.4 kg)
(BMI = 27.3 kg/m2). Blood pressure is 130/82 mm Hg. Findings on cardiovascular and
pulmonary examinations are normal. He has a mildly enlarged prostate without any
nodules.
Laboratory test results:
Total testosterone = 189 ng/dL (6.6 nmol/L) (reference range, 300-900 ng/dL [10.4-31.2
nmol/L])
Prostate-specific antigen = 2.1 ng/mL (2.1 µg/L) (reference range, <6.5 ng/mL [<6.5 µg/L])
Complete blood cell count, normal
158
Which of the following adverse effects is this patient most
likely to experience if testosterone replacement therapy is
initiated?
A.
B.
C.
D.
E.
Acute urinary retention
Prostate-specific antigen elevation above 4 ng/mL (>4 µg/L)
Myocardial infarction
Erythrocytosis
Stroke
Learning objective:
Anticipate the most likely adverse effect of testosterone therapy in older men.
159
Question 64:Adrenal Disorders
You are called from the emergency department for advice about a 28-year-old man
with a right-sided, firm testicular lump and abnormal abdominal CT findings (see
image). The patient is intoxicated, and he has been having abdominal pain and
vomiting. The patient says he has adrenal insufficiency and has a wallet card
confirming this. The patient's abdominal CT scan reveals bilateral 16-cm
heterogeneous adrenal masses (- 20 Hounsfield units).
160
After you recommend intravenous hydrocortisone, you
explain to the emergency department physician that this
man most likely has which of the following?
A.
B.
C.
D.
E.
Adrenomyeloneuropathy
Congenital adrenal hyperplasia
Autoimmune polyglandular syndrome type 2
Bilateral adrenal hemorrhage
Metastatic testicular carcinoma
Learning objective:
To appreciate that adrenal enlargement—particularly adrenal myelolipoma—
may complicate the course of patients with poorly controlled congenital adrenal
hyperplasia.
161
Question 65:Lipids/Obesity
You are asked to see a 32-year-old woman in her 29th week of pregnancy regarding a
lipemic blood sample. She presented the day before with vaginal bleeding and uterine
contractions and was admitted for observation, but these problems have now abated.
She has been in general good health and takes no medications. Her pregnancy has been
unremarkable except for weight gain greater than recommended (33 lb [15 kg]). The
patient has no history of hyperlipidemia, hypertension, or diabetes (including during a
previous pregnancy when she had a formal evaluation for gestational diabetes). She
reports a healthy childhood with no abnormalities of growth and development. She has
no history of recurrent gastrointestinal symptoms, abdominal pain, or pancreatitis. She is
unsure whether there is a history of hyperlipidemia in her family members.
On physical examination, her height is 66 in (167.6 cm) and weight is 200 lb (90.9 kg)
(BMI = 32.3 kg/m2). Blood pressure is 96/57 mm Hg. She has several clusters of eruptive
xanthomata across her back and on the dorsal aspects of her arms. Her abdomen is
gravid but not tender.
162
Laboratory test results (sample drawn while fasting):
Total cholesterol = 324 mg/dL (8.39 mmol/L) (reference range [optimal], <200 mg/dL
[<5.18 mmol/L])
Triglycerides = 2677 mg/dL (30.25 mmol/L) (reference range [optimal], <150 mg/dL
[<3.88 mmol/L])
HDL cholesterol = 42 mg/dL (1.09 mmol/L) (reference range [optimal], >60 mg/dL [>1.55
mmol/L])
Glucose = 76 mg/dL (4.2 mmol/L) (reference range, 70-99 mg/dL [3.9-5.5 mmol/L])
TSH = 1.2 mIU/L (reference range, 0.5-5.0 mIU/L)
Her blood glucose concentration 60 minutes after a 50-g oral glucose drink was 121
mg/dL (6.7 mmol/L) at 27 weeks' gestation.
163
Which of the following is the best next step in
management?
A.
B.
C.
D.
E.
Prescribe gemfibrozil
Recommend a fat-restricted diet
Provide total parenteral nutrition with minimum fat
Prescribe simvastatin
Perform plasma apheresis
Learning objective:
Select the appropriate strategy to manage severe hypertriglyceridemia during
pregnancy.
164
Question 66:Diabetes Mellitus and
Other Carbohydrate Disorders
A 32-year-old woman with type 1 diabetes is in her second trimester of pregnancy and
presents to the ophthalmologist for a dilated eye examination. She has no known history
of diabetic retinopathy or any other diabetes-associated complications. The upper image
shows a picture of her dilated fundus from an examination several years ago, and the
lower image shows a picture from her current examination.
Upper
Image
165
Lower
Image
The images shown depict which of the following:
Answer Upper Image
Lower Image
A.
Normal retina
B.
Normal retina
Microaneurysms
Nonproliferative diabetic retinopathy
with retinal hemorrhages and hard
exudates
C.
Nonproliferative diabetic retinopathy
Proliferative diabetic retinopathy
D.
Nonproliferative diabetic retinopathy
Proliferative retinopathy with laser scars
E.
Normal retina
Proliferative diabetic retinopathy
Learning objective:
Characterize diabetic retinopathy and explain the effects of pregnancy on
retinopathy progression.
166
Question 67:Lipids/Obesity
A 48-year-old woman with cardiovascular disease and a 10-year history of type 2 diabetes mellitus is
referred by her internist for more intensive lipid-lowering therapy. While on her current regimen of
atorvastatin, 80 mg daily, she has recently required a stent for a new right coronary artery occlusion.
On metformin and once-daily, long-acting insulin, her hemoglobin A1c level is less than 7.0% (<53
mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol]). During the past 3 years, the patient has
gained 30 lb (13.6 kg).
Laboratory test results:
Total cholesterol = 160 mg/dL (4.14 mmol/L) (reference range [optimal], <200 mg/dL [<5.18 mmol/L])
Triglycerides = 300 mg/dL (3.39 mmol/L) (reference range [optimal], <150 mg/dL [<3.88 mmol/L])
HDL cholesterol = 35 mg/dL (0.91 mmol/L) (reference range [optimal], >60 mg/dL [>1.55 mmol/L])
LDL cholesterol = 65 mg/dL (1.68 mmol/L) (reference range [optimal], <100 mg/dL [<2.59 mmol/L])
Non-HDL cholesterol = 125 mg/dL (3.24 mmol/L) (reference range [optimal], <130 mg/dL [<3.37
mmol/L])
In addition to encouraging exercise and weight loss, you recommend fenofibrate as an approach to
reduce her non-HDL cholesterol.
167
Which of the following might be an additional benefit of
fenofibrate treatment in this patient with type 2 diabetes?
A.
B.
C.
D.
E.
Decreased hemoglobin A1c level
Decreased proteinuria
Decreased blood pressure
Decreased retinopathy
Increased insulin sensitivity
Learning objective:
Use combined lipid-lowering therapies in patients with cardiovascular disease.
168
Question 68:Diabetes Mellitus and
Other Carbohydrate Disorders
A 48-year-old woman with type 2 diabetes mellitus presents for a follow-up visit. Her glycemic
control has recently worsened and a change in therapy is needed. Her diabetes is currently
treated with glimepiride, 8 mg daily, in conjunction with metformin, 1000 mg twice daily. A
review of her blood glucose values reveals the following profile:
Fasting blood glucose = 140-170 mg/dL (7.8-9.4 mmol/L) (reference range, 70-99 mg/dL [3.95.5 mmol/L])
2-Hour postmeal blood glucose = 180-220 mg/dL (10.0-12.2 mmol/L)
She has no symptomatic or documented hypoglycemia. She expresses concern over the
weight gain that she has experienced while on sulfonylurea therapy and does not want to
consider therapies that might exacerbate this further. She has not been adherent to
recommended lifestyle modifications.
On physical examination, she is an obese woman without any cushingoid features. Her height
is 65.5 in (166.4 cm), and weight is 190 lb (86.4 kg) (BMI = 31.1 kg/m2).
169
Laboratory test results:
Hemoglobin A1c = 7.6% (60 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
Sodium = 138 mEq/L (138 mmol/L) (reference range, 136-142 mEq/L [136-142 mmol/L])
Potassium = 4.5 mEq/L (4.5 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
Creatinine = 0.8 mg/dL (70.7 μmol/L) (reference range, 0.6-1.1 mg/dL [53.0-97.2 μmol/L])
Urinary albumin excretion = 10 mg/24 h (reference range, <25 mg/24 h)
170
In addition to optimizing diet and exercise therapy, and
keeping in mind the patient's concerns, which of the
following would be the best therapeutic addition?
A.
B.
C.
D.
E.
Basal insulin at bedtime
A thiazolidinedione
Rapid-acting insulin at mealtime
A sodium-glucose cotransporter 2 inhibitor
An amylin analogue
Learning objective:
Appropriately recommend sodium-glucose cotransporter 2 inhibitor therapy in a
patient with type 2 diabetes mellitus.
171
Question 69:Thyroid Disorders
A 55-year-old man presented 3 months ago with a solitary 3-cm nodule in the left thyroid
lobe. Findings from an aspiration biopsy show typical features of papillary thyroid cancer
including nuclear inclusions. Near-total thyroidectomy is performed. A 3.5-cm papillary
thyroid cancer is found, and 2 of 5 left paratracheal lymph nodes are positive for
metastases. No gross or capsular invasion is noted. Some areas of the malignancy have
a solid architecture, but there is no evidence of vascular invasion.
Postoperatively, he received 125 mCi of radioactive iodine with recombinant human TSH
support to treat residual uptake in the thyroid bed. No distant metastases are present in
the posttherapy scan. He is prescribed suppressive thyroid hormone therapy with
subsequent suppression of his serum TSH concentration to 0.08 mIU/L (reference range,
0.5-5.0 mIU/L).
Six months later, his serum TSH concentration is 0.38 mIU/L and his thyroglobulin
concentration is 28 ng/mL (28 µg/L) with undetectable thyroglobulin antibodies.
172
Which of the following steps would be most helpful now?
A.
B.
C.
D.
E.
Perform MRI of the cervical area
Perform neck ultrasonography
Refer him back to the surgeon to perform a right paratracheal dissection
Increase the dosage of thyroid hormone therapy to titrate to a TSH
concentration less than 0.1 mIU/L and recheck serum TSH and
thyroglobulin in 6 weeks
Perform a recombinant human TSH-stimulated radioiodine whole-body
scan
Learning objective:
Determine the best management for a patient with a history of thyroid cancer
when an increasing thyroglobulin level is observed.
173
Question 70:Female Reproduction
A 37-year-old new mother comes to see you for alactogenesis 7 days postpartum. Two and a
half years ago, she had a pregnancy that was complicated by preeclampsia and labor was
subsequently induced. The vaginal delivery was complicated by a 1300-cc hemorrhage. She
did not try to breastfeed the baby because of her medical complications. She required fertility
treatment with gonadotropins to become pregnant the second time. After her current delivery,
she noted colostrum, but no milk has come in.
On physical examination, her blood pressure is 110/60 mm Hg. Her height is 66 in (167.6 cm),
and weight is 242 lb (110 kg) (BMI = 39.1 kg/m2). Her breast examination is remarkable for
lack of venous engorgement and soft breast texture without palpable glandular tissue.
Laboratory test results:
Prolactin = 9 ng/mL (1.3 nmol/L) (reference range [nonlactating women], 4-30 ng/mL [0.171.30 nmol/L]; [lactating women], 10-200 ng/mL [0.43-8.70 nmol/L])
TSH = 0.55 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 0.7 ng/dL (9.01 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
Cortisol (8 AM) = 23.1 μg/dL (637.3 nmol/L) (reference range, 5-25 μg/dL [137.9-689.7
nmol/L])
174
Which of the following is the most likely cause of this
patient's alactogenesis?
A.
B.
C.
D.
E.
Primary hypothyroidism
Secondary hypothyroidism
Cushing syndrome
Lymphocytic hypophysitis
Sheehan syndrome
Learning objective:
Diagnose the cause of postpartum alactogenesis.
175
Question 71:Pituitary and
Neuroendocrine Disorders
A colleague refers a 28-year-old woman to your clinic for evaluation. A pituitary adenoma was
incidentally discovered on cranial MRI performed to investigate headache. She reports no change in
appearance or weight. She has a regular menstrual cycle; her last menstrual period was 1 month ago,
and a pregnancy test obtained yesterday is negative. She is currently sexually active, and she and her
husband would like to conceive as soon as possible.
On physical examination, she has no hirsutism, acne, and or obvious features of GH or cortisol
excess. Her height is 62 in (157.5 cm), and weight is 123 lb (56 kg) (BMI = 22.5 kg/m2). Her blood
pressure is 118/69 mm Hg.
Laboratory test results:
TSH = 1.8 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 1.1 ng/dL (14.2 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
Cortisol (8 AM) = 18 μg/dL (496.6 nmol/L) (reference range, 5.0-25.0 μg/dL [137.9-689.7 nmol/L])
IGF-1 = 168 ng/mL (22.0 nmol/L) (reference range, 117-321 ng/mL [15.3-42.1 nmol/L])
Prolactin = 28 ng/mL (1.2 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30 nmol/L])
176
MRI shows a 9-mm, low-attenuation lesion in the center and right side of the
pituitary gland (see images, coronal image on the left and sagittal image on the
right). It elevates the pituitary gland overlying it, abutting and minimally
compressing the left side of the optic chiasm and deviating the pituitary stalk to
the left. Findings on visual field assessment are normal.
177
Which of the following is the best management option?
A.
B.
C.
D.
E.
Refer for pituitary surgery
Initiate cabergoline therapy
Initiate octreotide therapy
Initiate metformin therapy
Perform ovarian ultrasonography
Learning objective:
Devise an appropriate follow-up plan of an incidentally discovered pituitary
microadenoma and explain the impact of pregnancy on pituitary volume.
178
Question 72:Diabetes Mellitus and
Other Carbohydrate Disorders
You are asked to assist in the management of a hospitalized 67-year-old man who is recovering from a
myocardial infarction. The patient's medical history is notable for obesity, obstructive sleep apnea,
hypertension, and prediabetes. Cardiac catheterization performed subsequent to his admission has
revealed multivessel coronary artery disease. The patient's medical team has recommended that he
begin statin therapy to reduce his risk of future cardiovascular events; however, the patient is aware
that statin therapy may increase his risk of progression to diabetes and he therefore wishes to discuss
this treatment further.
Laboratory test results:
Hemoglobin A1c = 5.9% (41 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
Creatinine = 0.8 mg/dL (70.7 µmol/L) (reference range, 0.7-1.3 mg/dL [61.9-114.9 µmol/L])
Total cholesterol = 176 mg/dL (4.56 mmol/L) (reference range [optimal], <200 mg/dL [<5.18 mmol/L])
LDL cholesterol = 101 mg/dL (2.62 mmol/L) (reference range [optimal], <100 mg/dL [<2.59 mmol/L])
HDL cholesterol = 41 mg/dL (1.06 mmol/L) (reference range [optimal], >60 mg/dL [>1.55 mmol/L])
Triglycerides = 172 mg/dL (1.94 mmol/L) (reference range [optimal], <150 mg/dL [<3.88 mmol/L])
Liver function tests, within normal limits
179
In addition to intensive lifestyle modification, which of the
following should you recommend to this patient now?
A.
B.
C.
D.
E.
Low-intensity statin therapy
High-intensity statin therapy
High-intensity statin therapy plus metformin
Low-intensity statin therapy plus fenofibrate
Fenofibrate monotherapy
Learning objective:
Counsel a patient with prediabetes and coronary disease on the risks and
benefits of statin therapy.
180
Question 73:Male Reproduction
A 27-year-old man comes to the endocrine clinic for evaluation of infertility. The patient
and his wife have been trying for pregnancy for the past 2 years without success. His wife
has normal menstrual cycles and findings from a thorough gynecologic evaluation are
normal. The couple has been timing sexual intercourse around her ovulation. He is now
referred to you for evaluation of possible male-factor infertility.
The patient underwent puberty at age 13 years and started shaving at the same time as
his peers. He recalls some increase in testicular size at puberty along with development of
bilateral gynecomastia, which has remained stable. His sense of smell is normal. He
reports normal libido and erectile function. He takes no medications.
On physical examination, he is a well-developed man without eunuchoid habitus. His
blood pressure is 120/72 mm Hg. His height is 69 in (175.3 cm), and weight is 180 lb
(81.8 kg) (BMI = 26.6 kg/m2). He has normal axillary and chest hair. There is bilateral,
nontender gynecomastia, 6 x 4 cm on the right side and 5 x 5 cm on the left side. There is
no galactorrhea, nipple retraction, or skin discoloration. His phallus and scrotum are
normal. His testes are firm and 4 mL bilaterally. His muscle bulk is slightly reduced, but
tone and power are normal.
181
Laboratory test results:
Morning total testosterone (by tandem mass spectrometry) = 349 ng/dL (12.1 nmol/L)
(reference range, 300-900 ng/dL [10.4-31.2 nmol/L])
TSH = 2.1 mIU/L (reference range, 0.5-5.0 mIU/L)
Azoospermia is documented on semen analysis (2 specimens, each taken after 3 days of
abstinence).
182
Which of the following should be the next diagnostic step in
this patient's evaluation?
A.
B.
C.
D.
E.
Measurement of dihydrotestosterone
Testicular ultrasonography
Measurement of gonadotropins
Testicular biopsy
Mammography
Learning objective:
Describe the clinical presentation of a man with mosaic Klinefelter syndrome
and recommend appropriate diagnostic tests.
183
Question 74:Thyroid Disorders
A 37-year-old man is referred to you for treatment of hyperthyroidism. He was in good health until 2 years ago
when he developed typical hyperthyroid symptoms and Graves disease was diagnosed. He was seen by an
endocrinologist who treated him with radioactive iodine (131I). Records of the radioactive iodine uptake, scan,
and estimate of thyroid size are not available.
Soon after the 131I treatment, the patient moved to your city and did not visit a physician until today's
appointment. He is taking no medications.
Laboratory test results:
Serum free T4 = 1.6 ng/dL (20.6 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
Serum total T3 = 134 ng/dL (2.1 nmol/L) (reference range, 70-200 ng/dL [1.08-3.08 nmol/L])
Serum TSH = 0.28 mIU/L (reference range, 0.5-5.0 mIU/L)
His history is unremarkable, except for smoking 1 and a half packs of cigarettes daily for 15 years. He
acknowledges that his eyes are large but reports they have been stable in appearance for the past 2 years.
On eye examination, he has globe protrusion, upper-lid edema, and injection of the conjunctivae, primarily on
the right side. Hertel measurements are 24 mm on the right and 21 mm on the left (baseline 104 mm).
Extraocular muscle movements are intact, and both visual acuity and color vision are normal. His thyroid gland
is minimally enlarged, firm, and without nodules. The rest of the examination findings are normal and reveal no
evidence of hyperthyroidism.
184
In addition to referring him to a smoking cessation program,
which of the following actions would you now recommend?
A.
B.
C.
D.
E.
Administer another dose of 131I
Prescribe atenolol, 50 mg daily
Prescribe methimazole, 20 mg daily
Measure serum thyroid-stimulating immunoglobulin
Follow-up with serum TSH measurements at 6-month intervals
Learning objective:
Describe the course of thyroid function in patients with Graves disease treated
with 131I.
185
Question 75:Diabetes Mellitus and
Other Carbohydrate Disorders
A 62-year-old African American man with a 10-year history of type 2 diabetes mellitus
complicated by microalbuminuria and nonproliferative retinopathy returns for a follow-up
appointment. He is currently on metformin and an insulin regimen that includes insulin
glargine, 50 units daily, and insulin aspart, 12 units with each of his 3 daily meals. Family
history is pertinent for type 2 diabetes mellitus in both parents and sickle cell trait in
several family members.
At his last appointment, his hemoglobin A1c value was 9.6% (81 mmol/mol) (reference
range, 4.0%-5.6% [20-38 mmol/mol]). However, his insulin doses were not increased at
that visit because he had reported fairly frequent episodes of hypoglycemia. He describes
excellent adherence to his prescribed regimen. Most of his fasting and premeal blood
glucose values are between 90 and 150 mg/dL (5.0-8.3 mmol/L) (reference range, 70-99
mg/dL [3.9-5.5 mmol/L]); however, he has frequent hypoglycemia occurring 1 to 2 hours
after breakfast, before his evening meal, and during the overnight hours, sometimes
followed by hyperglycemia.
186
Laboratory test results:
Hemoglobin A1c = 9.1% (76 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
Fructosamine = 299 µmol/L (reference range, 190-270 µmol/L)
Creatinine = 1.2 mg/dL (106.1 µmol/L) (reference range, 0.7-1.3 mg/dL [61.9-114.9
µmol/L])
Estimated glomerular filtration rate = 78.6 mL/min per 1.73 m2 (reference range, >60
mL/min per 1.73 m2)
TSH = 2.2 mIU/L (reference range, 0.5-5.0 mIU/L)
Serum electrolytes and liver function tests, within normal limits
187
Which of the following should you recommend now?
A. Measurement of fingerstick blood glucose values 2 hours after all meals
B. Measurement of fingerstick blood glucose values at 2:00 to 3:00 AM several
nights per week
C. Diagnostic 72-hour glucose sensor placement
D. Repeated hemoglobin A1c testing using a boronate affinity
chromatography method
E. Cosyntropin stimulation test
Learning objective:
Identify clinical conditions that may affect the reliability of hemoglobin A1c
assays.
188
Question 76:Thyroid Disorders
You are consulted to help manage the thyroid hormone therapy of a 71-year-•
old man with
hypothyroidism. His serum TSH concentration has become progressively elevated during
hospitalization after a cerebrovascular accident. The patient has a preexisting diagnosis
of hypothyroidism and had been taking levothyroxine, 88 mcg daily as an outpatient,
which resulted in serum TSH concentrations of 3.2 and 4.1 mIU/L at his last 2 outpatient
visits. The patient has not yet been allowed to resume oral medication or feeding
because of his impaired mental status and persistent swallowing difficulties after his
stroke.
Currently, he is receiving continuous tube feedings, and medications are being delivered
via the nasogastric tube.
Other than altered mental status, his physical examination findings are unremarkable. His
thyroid gland is normal to palpation. You review the laboratory data from his hospital stay,
which include the following thyroid function tests and levothyroxine dosages.
189
Timing After Admission
Measurement
1 Week
2 Weeks
3 Weeks
TSH
15.7 mIU/L
23.0 mIU/L
35.0 mIU/L
Free T4
....
0.6 ng/dL (7.7 pmol/L)
0.5 ng/dL (6.4 pmol/L)
Total T3
....
....
60 ng/dL (0.9 nmol/L)
Levothyroxine dosage
88 mcg daily
100 mcg daily
112 mcg daily
Reference ranges: TSH, 0.5-5.0 mIU/L; free T4, 0.8-1.8 ng/dL (10.30-23.17 pmol/L); total
T3, 70-200 ng/dL (1.08-3.08 nmol/L).
190
Which of the following initial recommendations will you
make to the team caring for the patient?
A.
B.
C.
D.
E.
Switch his thyroid hormone replacement to liothyronine, 25 mcg orally
twice daily
Add liothyronine, 5 mcg orally twice daily
Increase his oral levothyroxine dosage to 250 mcg daily
Switch his regimen to levothyroxine, 75 mcg daily given
intravenously
Administer intravenous liothyronine, 5 mcg twice daily
Learning objective:
Manage levothyroxine therapy in a hospitalized patient receiving enteral
feeding.
191
Question 77:Adrenal Disorders
You have been asked to see a 17-year-old woman for newly recognized hypertension
and hypokalemia. Because of primary amenorrhea, her primary care physician obtained
a karyotype. The findings are 46,XX. She is of Dutch Mennonite heritage. Physical
examination reveals a blood pressure of 152/98 mm Hg. There are no flank or epigastric
bruits. There are no features of Cushing syndrome. However, she lacks development of
secondary sexual characteristics, and secondary sex hair is minimal.
Laboratory test results:
Sodium = 146 mEq/L (146 mmol/L) (reference range, 136-142 mEq/L [136-142 mmol/L])
Potassium = 3.1 mEq/L (3.1 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
DHEA-S = 14 μg/dL (0.38 µmol/L) (reference range, 44-332 µg/dL [1.19-9.00 µmol/L])
Plasma aldosterone concentration, undetectable
Plasma renin activity, undetectable
192
Which of the following is most likely responsible for this
presentation?
A.
B.
C.
D.
E.
11β-Hydroxylase (CYP11B1) deficiency
Deoxycorticosterone-producing tumor
Primary cortisol resistance
11β-Hydroxysteroid dehydrogenase type 2 deficiency
17α-Hydroxylase (CYP17A1) deficiency
Learning objective:
Identify causes of hypertension and hypokalemia not associated with
aldosterone excess.
193
Question 78:Lipids/Obesity
A 57-year-old man presents to discuss lipid-lowering therapy. He has never had cardiovascular
disease, does not smoke cigarettes, and does not have a family history of premature cardiovascular
disease. He has hypertension controlled on only one medication.
On physical examination, his height is 66 in (167.6 cm) and weight is 150 lb (68.2 kg) (BMI = 24.2
kg/m2). His blood pressure is 122/76 mm Hg, and heart rate is 72 beats/min. Examination findings
are normal.
Fasting laboratory test results:
Total cholesterol = 166 mg/dL (4.30 mmol/L) (reference range [optimal], <200 mg/dL [<5.18 mmol/L])
HDL cholesterol = 37 mg/dL (0.96 mmol/L) (reference range [optimal], >60 mg/dL [>1.55 mmol/L])
LDL cholesterol = 102 mg/dL (2.64 mmol/L) (reference range [optimal], <100 mg/dL [<2.59 mmol/L])
Triglycerides = 138 mg/dL (1.56 mmol/L) (reference range [optimal], <150 mg/dL [<3.88 mmol/L])
You enter his values into the American College of Cardiology/American Heart Association
atherosclerotic cardiovascular disease risk calculator. His 10-year risk of a cardiovascular event is
estimated to be 7.5% with a lifetime risk of 50%.
194
Which of the following factors is the strongest indicator for
starting a statin in this patient?
A.
B.
C.
D.
E.
LDL-cholesterol concentration above the target of 100 mg/dL (2.59
mmol/L)
HDL-cholesterol concentration below the target of 40 mg/dL (1.04 mmol/L)
Age (older than 50 years)
Diagnosis of hypertension
Estimated 10-year risk of a cardiovascular event of 7.5%
Learning objective:
Recommend lipid-lowering therapy with statins on the basis of global
cardiovascular risk rather than on specific lipid targets.
195
Question 79:Bone and Mineral
Metabolism
You are asked to consult regarding hypocalcemia in a previously healthy 42-year-old
woman who was hospitalized because of a 1-month history of progressive bloody
diarrhea, anorexia, and a 22-lb (10-kg) weight loss. For 2 days before admission, she had
a fever, chills, and lightheadedness. In addition, she has experienced progressive
weakness, muscle cramping, and palpitations. Ulcerative colitis was diagnosed following
emergency flexible sigmoidoscopy the night of admission.
Since admission, she has received approximately 3 L of intravenous normal saline and
has been started on prednisone, 80 mg daily, and mesalamine.
On physical examination, she is a thin, ill-appearing woman. Her height is 65 in (165.1
cm), and weight is 105 lb (47.7 kg) (BMI = 17.5 kg/m2). She has temporal wasting and
tenting on skin examination. Abdominal examination reveals diminished bowel sounds
and diffuse discomfort to palpation without rebound tenderness. Chvostek sign is
positive. There is no evidence of vitiligo or hyperpigmentation.
196
Laboratory test results:
Calcium = 7.0 mg/dL (1.75 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L])
Albumin = 2.9 g/dL (29 g/L) (reference range, 3.5-5.0 g/dL [35-50 g/L])
Phosphorus = 2.6 mg/dL (0.84 mmol/L) (reference range, 2.3-4.7 mg/dL [0.7-1.5
mmol/L])
Magnesium = 0.4 mg/dL (0.16 mmol/L) (reference range, 1.5-2.3 mg/dL [0.6-0.9 mmol/L])
Potassium = 3.0 mEq/L (3.0 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
Electrocardiogram documents premature ventricular contractions, widening of the QRS
complex, and peaking of the T waves.
197
Which of the following patterns of PTH and vitamin D levels
would be most likely?
A.
↑
1,25Dihydroxyvitamin D
↓
B.
↑
↑
C.
↓
↑
D.
↓
↓
E.
normal
↑
PTH
Learning objective:
Diagnose hypomagnesemia and predict the effect on calcium, parathyroid
hormone, and vitamin D metabolism.
198
Question 80:Pituitary and
Neuroendocrine Disorders
A 56-year-old woman presents with recent-onset headache, nausea, and decreased
stamina. She reports increased thirst and fluid intake and for the past 3 weeks, she has
been getting up several times a night to urinate. She was previously healthy, takes no
medication, and has never smoked cigarettes. Her menses stopped at age 50 years.
On physical examination, her blood pressure is 100/62 mm Hg and pulse rate is 80
beats/min. There are no features suggestive of GH or cortisol excess. Extraocular
movements are intact and there are no visual field defects detected on confrontation
testing. There is no edema.
199
Laboratory tests results:
Sodium = 147 mEq/L (147 mmol/L) (reference range, 136-142 mEq/L [136-142 mmol/L])
Potassium = 3.9 mEq/L (3.9 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
Calcium = 9.1 mg/dL (2.3 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6 mmol/L])
Glucose = 92 mg/dL (5.1 mmol/L) (reference range, 70-99 mg/dL [3.9-5.5 mmol/L])
Creatinine = 1.1 mg/dL (97.2 µmol/L) (reference range, 0.6-1.1 mg/dL [53.0-97.2 µmol/L])
Prolactin = 38 ng/mL (1.7 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30 nmol/L])
IGF-1 = 23 ng/mL (3.0 nmol/L) (reference range, 78-220 ng/mL [10.2-28.8 nmol/L])
Morning cortisol = 3.0 µg/dL (82.8 nmol/L) (reference range, 5.0-25 μg/dL [137.9-689.7
nmol/L])
TSH = 1.0 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 0.6 ng/dL (7.7 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
FSH = 1.0 mIU/mL (1.0 IU/L) (reference range, >30 mIU/mL [>30 IU/L])
Urinary sodium = 24 mEq/L (24 mmol/L) (reference range, 40-217 mEq/24 h [40-217
mmol/d])
Urinary osmolality = 120 mOsm/kg (120 mmol/kg) (reference range, 150-1150 mOsm/kg
[150-1150 mmol/kg])
200
Brain MRI shows a sellar mass that does not exert pressure on the optic apparatus (see
image). Hydrocortisone, desmopressin, and levothyroxine are administered with good
effect.
201
Which of the following should you advise next?
A.
B.
C.
D.
E.
A water deprivation test
Measurement of serum α-fetoprotein
CT of the chest, abdomen, and pelvis
Measurement of serum hCG
Iron studies (iron, total iron binding capacity, ferritin)
Learning objective:
Recognize the possibility of metastatic disease to the pituitary in a patient
presenting with anterior hypopituitarism and diabetes insipidus.
202
Question 81:Diabetes Mellitus and
Other Carbohydrate Disorders
You are asked to evaluate a hospitalized 69-year-old man with a history of type 2
diabetes mellitus, hypertension, and hyperlipidemia. He just underwent a coronary
artery bypass graft procedure. Postoperative glycemic control was adequately
achieved with intravenous insulin infusion.
Over the past 24 hours, intravenous insulin infusion rates ranging between 1.3 and
3.1 units per hour have resulted in fingerstick blood glucose readings between 109
and 181 mg/dL (6.1-10.0 mmol/L). During the 8-hour period overnight, his glycemic
control was stable on an insulin infusion rate of 1.3 units per hour. The surgical
team will discontinue the intravenous insulin infusion today and has requested that
you assist with his further diabetes management.
203
A transition to which of the following is the best next step in
this patient's care?
A.
B.
C.
D.
E.
Metformin monotherapy
Correction doses of a subcutaneous rapid-acting insulin before intake of
meals
Subcutaneous insulin glargine at a dosage of 25 units once daily
Subcutaneous insulin glargine at a dosage of 40 units once daily
Subcutaneous regular insulin at a dosage of 10 units every 6 hours
Learning objective:
Guide the transition of an intravenous insulin infusion regimen to a
subcutaneous insulin regimen.
204
Question 82:Thyroid Disorders
A 63-•
year-old woman is referred to you after having undergone 18F- •
fluorodeoxyglucose
positron emission tomography (FDG- PET) for surveillance of her lung cancer. She underwent
a left lung lobectomy 2 years ago and she has been thought to be free of disease on the basis
of her imaging studies. On this recent PET scan, no suspicious uptake was seen in the chest.
However, diffuse uptake was noted within the thyroid gland. She has no history of thyroid
problems. Tuberculosis was diagnosed several years ago; she was treated for 1 year with
antibiotics and was subsequently told she was cured.
On physical examination, her thyroid gland is palpable, nontender, and slightly enlarged. You
review the PET scan images; the FDG uptake is evident throughout both lobes of the thyroid
gland (see images). The standard uptake ratio value is 8.5. You order thyroid testing and
obtain the following results:
TSH = 3.9 mIU/L (reference range, 0.5-5.0 mIU/L)
Free T4 = 1.1 ng/dL (14.2 pmol/L) (reference range, 0.8-1.8 ng/dL [10.30-23.17 pmol/L])
TPO antibodies = 40 IU/mL (40 IU/L) (reference range, <2.0 IU/mL [<2.0 kIU/L])
205
206
Which of the following is the most likely explanation for the
uptake of FDG within this patient's thyroid gland?
A.
B.
C.
D.
E.
Hashimoto thyroiditis
Lung cancer metastases to the thyroid gland
Normal physiologic uptake within the thyroid gland
Graves disease
Tuberculosis affecting the thyroid gland
Learning objective:
Develop a differential diagnosis for the incidental finding of fluorodeoxyglucose
uptake within the thyroid gland.
207
Question 83:Adrenal Disorders
A 27-year-old woman seeks your advice at 6 weeks' gestation in her first pregnancy.
She has a history of salt-wasting congenital adrenal hyperplasia due to 21hydroxylase deficiency, for which she takes hydrocortisone and fludrocortisone. She
is concerned that her baby may have congenital adrenal hyperplasia.
208
Question 84:Female Reproduction
A 27-year-old woman presents to you for advice after unsuccessfully trying to get pregnant for 6 months.
She underwent menarche at age 10 years. Her menstrual cycles are regular; she menstruated every 28
days until age 17, but now she has a menses every 33 to 35 days. She has no acne, hirsutism, hot
flashes, or night sweats. She has gained weight since high school when she used to weigh 140 lb (63.6
kg). She has no history of pelvic surgery or sexually transmitted infections. Her husband has previously
fathered a child.
On physical examination, her blood pressure is 120/80 mm Hg. Her height is 63 in (160 cm), and weight
is 223 lb (101.4 kg) (BMI = 39.5 kg/m2). She has no acne or hirsutism. There is no galactorrhea on breast
examination. Findings on pelvic examination are normal.
Laboratory test results (day 19 of menstrual cycle):
TSH = 2.6 mIU/L (reference range, 0.5-5.0 mIU/L)
Prolactin = 8.6 ng/mL (0.4 nmol/L) (reference range, 4-30 ng/mL [0.17-1.30 nmol/L])
FSH = 8.1 mIU/mL (8.1 IU/L) (reference range [follicular], 4.0-36.0 mIU/mL [4.0-36.0 IU/L]; [luteal], 1.0-9.0
mIU/mL [1.0-9.0 IU/L])
Progesterone = 9.9 ng/mL (31.5 nmol/L) (reference range [follicular], ≤1.0 ng/mL [≤3.2 nmol/L]; [luteal],
2.0-20.0 ng/mL [6.4-63.6 nmol/L])
Hemoglobin A1c = 4.9% (30 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
hCG, negative
209
Which of the following is the best next step in this patient's
management?
A.
B.
C.
D.
E.
Measure serum 17-hydroxyprogesterone
Add dexamethasone, 0.5 mg at bedtime
Perform molecular genetic testing for CYP21A2 mutations in the
baby's father
Perform amniocentesis to determine fetal sex
Secure fetal DNA via chorionic villus sampling for CYP21A2 mutation
analysis
Learning objective:
To understand that congenital adrenal hyperplasia is an autosomal recessive
disorder.
210
How would you advise this patient to maximize her
chances of pregnancy?
A.
B.
C.
D.
E.
Time intercourse between days 11 and 21 of the menstrual cycle
Check an ovulation kit on cycle days 10, 12, and 14 and time intercourse
to the day the kit is positive
Measure a progesterone level 7 days before expected menses
Take basal body temperatures and time intercourse to the temperature rise
Lose weight to improve ovulation
Learning objective:
Recommend timed intercourse for couples planning pregnancy.
211
Question 85:Diabetes Mellitus and
Other Carbohydrate Disorders
You are asked to evaluate a 52-year-old African American woman with newly diagnosed
diabetes mellitus. She has recently completed a successful course of pegylated-interferon-α
and ribavirin therapy for chronic hepatitis C virus infection. Approximately 1 month after this
treatment was completed, she presented to the emergency department with weight loss,
fatigue, polydipsia, and polyuria. Diabetic ketoacidosis was diagnosed. She was admitted to
the hospital, and with appropriate management the ketoacidosis has quickly resolved. The
patient is receiving an intravenous insulin infusion at a rate of 0.5 units per hour. Over the past
10 hours, her glycemic control has been excellent, and no adjustments to her insulin infusion
rate have been required. The patient will begin eating solid food later this morning. Her renal
function and serum electrolytes are now within normal limits.
The patient has no personal or family history of diabetes. Laboratory testing for glutamic acid
decarboxylase autoantibodies was negative when performed at the start of her course of
antiviral therapy. She tolerated that therapy well, had an excellent response in her viral load,
and was without evidence of hyperglycemia during treatment. The patient is afebrile and has
normal physical examination findings. Her height is 66 in (167.6 cm), and weight is 160 lb (72.7
kg) (BMI = 25.8 kg/m2).
212
Which of the following is the best management plan?
A.
B.
C.
D.
E.
Transition from intravenous insulin infusion to a scheduled
subcutaneous basal-bolus insulin regimen
Transition from intravenous insulin infusion to twice-daily metformin
therapy
Discontinue all antihyperglycemic therapy but continue to monitor blood
glucose values
Begin high-dosage glucocorticoid therapy and continue the intravenous
insulin infusion
Consult gastroenterology for resumption of pegylated-interferon-α and
ribavirin therapy
Learning objective:
Manage new-onset diabetes in a patient with interferon-treated hepatitis C
infection.
213
Question 86:Male Reproduction
A 77-year-old man is referred to you for management of osteoporosis. A high-grade,
locally invasive prostate cancer was diagnosed 8 months ago after a screening
prostate-specific antigen level was found to be elevated. He was started on
androgen deprivation therapy with a GnRH agonist 6 months ago, along with
radiation therapy, and his prostate-specific antigen concentration is now
undetectable. His oncologist plans to continue androgen deprivation therapy for the
next 12 to 18 months. A screening DXA scan documented osteoporosis of the spine
(T score, -3.1) and femoral neck (T score, -2.9).
The patient has no known history of osteoporosis or fractures, but reports that he
has lost 2 in (5.1 cm) in height. His mother experienced a hip fracture at age 70
years. His other medical history is notable for gastroesophageal reflux disease. His
current medications include a proton-pump inhibitor and calcium citrate plus vitamin
D.
214
On physical examination, the patient has kyphosis. His pulse rate is 78 beats/min,
and blood pressure is 132/82 mm Hg. His height is 73 in (185.4 cm), and weight is
203 lb (92.3 kg) (BMI = 26.8 kg/m2). Findings on cardiac examination are normal.
His testes are 15 mL bilaterally.
Relevant laboratory test results:
25-Hydroxyvitamin D = 39 ng/mL (97.3 nmol/L) (reference range [optimal], 25-80
ng/mL [62.4-199.7 nmol/L])
Calcium = 9.7 mg/dL (2.4 mmol/L) (reference range, 8.2-10.2 mg/dL [2.1-2.6
mmol/L])
PTH = 32 pg/mL (32 ng/L) (reference range, 10-65 pg/mL [10-65 ng/L])
215
Which of the following medications would be the best initial
choice in treating this patient's osteoporosis?
A.
B.
C.
D.
E.
Denosumab
Alendronate
Nasal calcitonin
Raloxifene
Recombinant PTH
Learning objective:
Select the optimal treatment for osteoporosis in men undergoing androgen
deprivation therapy.
216
Question 87:Bone and Mineral
Metabolism
You are asked to see an 18-year-old woman for evaluation of bone health. She has
a history of anorexia nervosa first diagnosed at age 4 years. She has required
multiple inpatient admissions and has struggled with maintaining normal weight
despite psychiatric intervention. Other medical problems include anemia,
carotenemia, depression, and social anxiety for which she takes a selective
serotonin reuptake inhibitor daily. She has not had a menstrual period in more than
2 years. She is not currently taking an oral contraceptive because she is fearful this
will cause weight gain. At age 17 years she sustained a T11 compression fracture
after tripping on a rug.
On physical examination, she is a malnourished woman appearing older than her
stated age. She has diffuse alopecia and bilateral temporal wasting. Her height is
61 in (154.9 cm), and weight is 61 lb (27.7 kg) (BMI = 11.5 kg/m2). Her blood
pressure is 97/61 mm Hg, and pulse rate is 69 beats/min. Muscle strength in her
upper and lower extremities is 3/5 bilaterally.
217
Laboratory test results:
LH = 0.3 mIU/mL (0.3 IU/L) (reference ranges, 1.0-18.0 mIU/mL [1.0-18.0 IU/L]
[follicular]; 20.0-80.0 mIU/mL [20.0-80.0 IU/L] [midcycle]; 0.5-18.0 mIU/mL [0.5-18.0
IU/L] [luteal])
FSH = 0.9 mlU/mL (0.9 IU/L) (reference ranges, 2.0-12.0 mIU/mL [2.0-12.0 IU/L]
[follicular]; 4.0-36.0 mIU/mL [4.0-36.0 IU/L] [midcycle]; 1.0-9.0 mIU/mL [1.0-9.0 IU/L]
[luteal])
Estradiol, undetectable
25-Hydroxyvitamin D = 18 ng/mL (44.9 nmol/L) (reference range [optimal], 25-80
ng/mL [62.4-199.7 nmol/L])
218
In addition to ongoing psychiatric care, the addition of calcium
supplementation, and the restoration of a normal vitamin D
level, which of the following treatment recommendations is
indicated to stabilize her bone density?
A.
B.
C.
D.
E.
Denosumab
A bisphosphonate
Low-dosage estradiol and progesterone
Weight-bearing exercise program
Teriparatide
Learning objective:
Recommend appropriate treatment of osteoporosis in women who are severely
underweight.
219
Question 88:Diabetes Mellitus and
Other Carbohydrate Disorders
A 53-year-old man with type 2 diabetes mellitus returns for a follow-up visit with concerns about
worsening peripheral neuropathy. He is currently treated with liraglutide, which he is tolerating without
any concerns. He has no diabetes-associated complications other than neuropathy, which is treated
with gabapentin, 200 mg 3 times daily, that he has taken regularly for the past 4 months. He has
experienced modest pain control on this treatment, but notes somnolence while driving. He practices
good foot care and has not had any acute foot ulcerations. However, over the last few months, he has
been experiencing a "pins and needles" sensation in his lower extremities bilaterally and periodic
severe pain, which occasionally restricts his walking. He also reports waking at night because of foot
pain. He has no calf pain.
On physical examination, he is in mild distress because of foot pain. His height is 76 in (193 cm), and
weight is 210 lb (95.5 kg) (BMI = 25.6 kg/m2). His blood pressure is 100/65 mm Hg, and pulse rate is
82 beats/min. Neurologic examination reveals loss of sensation on Semmes-Weinstein monofilament
testing and loss of ankle reflexes bilaterally. The rest of his examination findings are normal.
Laboratory test results:
Hemoglobin A1c = 5.8% (40 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
Vitamin B12 = 500 pg/mL (369 ng/L) (reference range, 180-914 pg/mL [180-914 ng/L])
220
Which of following is the best next therapeutic step?
A.
B.
C.
D.
E.
Increase the gabapentin dosage to 600 mg 3 times daily
Add treatment with acetaminophen and codeine
Add treatment with capsaicin cream
Add vitamin B12 replacement therapy
Switch gabapentin to pregabalin
Learning objective:
Manage pain in a patient with established diabetic neuropathy.
221
Question 89:Lipids/Obesity
You are seeing a 55-year-old Hispanic woman who underwent Roux-en-Y gastric bypass surgery 4 years
ago. She now presents with a 3-month history of abdominal pain and diarrhea. Her preoperative weight was
259 lb (117.7 kg) (BMI = 43.6 kg/m2); after surgery, her nadir weight was 161 lb (73.2 kg) and her current
weight is 190 lb (86.4 kg).
She is adherent to the prescribed dietary and vitamin supplement recommendations. Trying a gluten-free
diet did not ameliorate her symptoms. She describes her abdominal pain as discomfort with bloating and
gas. There is no discrete area of pain and no associated nausea or vomiting. She has 3 to 4 bowel
movements daily that are often loose and malodorous, but not greasy and not difficult to flush.
On physical examination, her height is 65 in (165.1 cm) and weight is 190 lb (86.4 kg) (BMI = 31.6 kg/m2).
Abdominal examination reveals hyperactive bowel sounds.
Laboratory test results:
Complete blood cell count, normal
Ferritin, normal
25-Hydroxyvitamin D = 33 ng/mL (82.4 nmol/L) (reference range [optimal], 25-80 ng/mL [62.4-199.7 nmol/L])
Hemoglobin A1c = 5.6% (38 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol])
222
Which test will most likely identify the cause of her
symptoms?
A.
B.
C.
D.
E.
Colonoscopy
Stool sample to test for enteric pathogens
48-Hour stool fat excretion
Tissue transglutaminase antibody measurement
Carbohydrate breath test
Learning objective:
Assess for small-bowel bacterial overgrowth as a cause of abdominal
symptoms and diarrhea in patients after Roux-en-Y gastric bypass.
223
Question 90:Adrenal Disorders
A 61-year-old woman with a 50 pack-year history of cigarette smoking presents with the recent
onset of hypertension and peripheral edema. She appears cachectic and chronically ill. Her
blood pressure is 182/104 mm Hg, and pulse rate is 94 beats/min. She has 4+ pretibial edema
and severe muscle weakness.
Laboratory test results:
Sodium = 134 mEq/L (134 mmol/L) (reference range, 136-142 mEq/L [136-142 mmol/L])
Potassium = 2.0 mEq/L (2.0 mmol/L) (reference range, 3.5-5.0 mEq/L [3.5-5.0 mmol/L])
Chloride = 90 mEq/L (90 mmol/L) (reference range, 96-106 mEq/L [96-106 mmol/L])
Bicarbonate = 42 mEq/L (42 mmol/L) (reference range, 21-28 mEq/L [21-28 mmol/L])
Serum urea nitrogen = 22 ng/dL (7.9 mmol/L) (reference range, 8-23 mg/dL [2.9-8.2 mmol/L])
Creatinine = 0.7 mg/dL (61.9 µmol/L) (reference range, 0.6-1.1 mg/dL [53.0-97.2 µmol/L])
Aldosterone = <1 ng/dL (<27.7 pmol/L) (reference range, 1-21 ng/dL [27.7-582.5 pmol/L])
Plasma renin activity = <0.1 ng/mL per h (reference range, 0.6-4.3 ng/mL per h)
Spironolactone, potassium chloride, and valsartan are initiated. CT of the chest and abdomen
shows bilateral adrenal enlargement, with a 2-cm left adrenal nodule (19 Hounsfield units) and
a large left inferior lobe lung mass.
224
Which of the following is the most likely cause of the
hypertension and hypokalemia in this patient?
A.
B.
C.
D.
E.
Adrenocortical carcinoma with pulmonary metastases
Liddle syndrome
Surreptitious use of diuretics
Ectopic ACTH-secreting small cell carcinoma of the lung
Aldosterone-secreting adrenal adenoma
Learning objective:
To understand the clinical and biochemical presentation of the ectopic ACTH
syndrome and differential diagnosis of patients with hypertension, hypokalemia,
and subnormal plasma renin and aldosterone.
225
Question 91:Diabetes Mellitus and
Other Carbohydrate Disorders
A 47-year-old man with an unremarkable medical history is referred for evaluation of
symptoms suggestive of hypoglycemia. These symptoms occur at variable times
and are characterized by sweating, tremor, and tachycardia. Most commonly,
symptoms occur when he wakes in the morning, but sometimes the symptoms
occur 1 to 2 hours after meals. The patient has thus started waking up 3 times
during the night to consume a snack, and he carries orange juice with him
constantly. These symptoms have been present to some degree for about 2 years,
but have worsened in the past 4 months.
Examination findings are unremarkable except for a BMI of 43 kg/m2. A 72-hour fast
is performed during which the patient is asymptomatic for the first 48 hours.
However, symptoms of neuroglycopenia eventually develop and blood is drawn for
laboratory testing. Then glucagon is administered, and glucose is measured 10, 20,
and 30 minutes after administration.
226
Laboratory values are shown in the Table.
Time
227
Glucose
Insulin
C-Peptide
Proinsulin
8:15 PM
44 mg/dL
(mmol/L)
11 µIU/mL
(76.4 pmol/L)
6.0 ng/mL
(2.0 nmol/L)
176.4 pg/mL
20 (pmol/L)
8:25 PM
58 mg/dL
(3.2 mmol/L)
...
...
...
8:35 PM
70 mg/dL
(3.9 mmol/L)
...
...
...
8:55 PM
75 mg/dL
(4.2 mmol/L)
...
...
...
Sulfonylurea
Screen
Negative
Which of the following would be appropriate management
now?
A.
B.
C.
D.
E.
Selective arterial calcium stimulation test
No further testing; instead, a consultation with a dietician to prescribe an
"anti-dumping"•diet
Abdominal CT with intravenous contrast
Transabdominal ultrasonography
Octreotide scan
Learning objective:
Recognize potential reasons for inconsistency in testing for hypoglycemic
disorders and choose optimal management strategies in a patient with
insulinoma presenting with both fasting and postprandial symptoms.
228

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