While performing a routine physical examination on a 42-year-old female you discover an apparent nodule in the left lobe of the thyroid measuring approximately 1 cm in diameter, which is confirmed on ... ultrasonography. The most appropriate next step in the evaluation of this finding is a A. serum calcitonin level B. serum free T3 level C. serum TSH level D. serum thyroglobulin level E. radionuclide thyroid scan A 45-year-old white male undergoes a health screening at his church. He has a carotid Doppler study, abdominal ultrasonography, heel densitometry, and a multiphasic blood panel. He receives a report indicating that all of the studies are normal, but a 0.7-cm thyroid nodule was noted. The TSH level is normal. He schedules a visit with you and brings you the report. A neck examination and ENT examination are normal, and you do not detect a nodule. You recommend (check one) A. a radionuclide thyroid scan B. T3, T4, and calcitonin levels C. repeat ultrasonography in 6-12 months D. a fine-needle biopsy E. hemithyroidectomy A 57-year-old previously healthy menopausal female presents to your office with a 1-year history of palpitations and an unintentional 10-lb weight loss. A review of systems is negative for tremors or visual changes. Vital signs include a blood pressure of 129/85 mm Hg and a heart rate of 110 beats/min. A physical examination is otherwise unremarkable except for a nontender, diffusely enlarged thyroid with no distinct nodules, and mild proptosis. Laboratory studies are significant for a TSH level<0.01 :U/mL (N 0.60-3.30), a free T3 level of 14.51 pg/mL (N 2.0-3.5), and a free T4 level of 4.52 ng/dL (N 0.71-1.40). A thyroid-stimulating immunoglobulin test is positive. In addition to a β-blocker, which one of the following is the most appropriate initial management? (check one) A. Radioactive iodine ablation B. Thyroidectomy C. Methimazole (Tapazole) D. Propylthiouracil (PTU) A 33-year-old white female presents with tremor and a history of weight loss. On examination she is found to have mild, regular tachycardia and exophthalmos. Laboratory tests confirm hyperthyroidism. Which one of the following treatments has been found to potentially worsen Grave's ophthalmopathy? (check one) A. Radioactive iodine B. Propylthiouracil C. Methimazole (Tapazole) D. Thyroid hormone replacement plus propylthiouracil E. Thyroidectomy Pretibial myxedema is a cutaneous manifestation of? (check one) A. Subclinical diabetes mellitus B. Collagen vascular disease C. Hyperlipidemia, type III D. Ischemia E. Graves’ disease A 70-year-old white female comes to your office for an initial visit. She has taken levothyroxine (Synthroid), 0.3 mg/day, for the last 20 years. Although a recent screening TSH was fully suppressed at <0.1 μU/mL, she claims that she has felt "awful" when previous physicians have attempted to lower her levothyroxine dosage. You explain that a serious potential complication of her current thyroid medication is: (check one) A. adrenal insufficiency B. carcinoma of the ovary C. carcinoma of the thyroid D. hip fracture E. renal failure A 42-year-old female is found to have a thyroid nodule during her annual physical examination. Her TSH level is normal. Ultrasonography of her thyroid gland shows a solitary nodule measuring 1.2 cm. Which one of the following would be most appropriate at this point? (check one) A. A radionuclide thyroid scan B. A fine-needle aspiration biopsy of the nodule C. Partial thyroidectomy D. Total thyroidectomy E. Reassurance A 25-year-old female who is 3 months post partum presents with multiple complaints, including increasing weakness and fatigue, intolerance to warm environments, a weight loss of 30 lb despite an increased appetite, difficulty sleeping, awareness that her heart is beating faster and "pounding" in her chest, increasing restlessness and difficulty concentrating, increased tremulousness, and a significant swelling in her neck. She takes no medication, has experienced no recent trauma, and has not ingested large amounts of iodine. When you examine her you find no exophthalmos or lid lag and no pretibial edema, but her skin is warm, smooth, and moist. You also find a smooth, non-nodular, nontender, enlarged thyroid gland, clear lungs, a resting tremor, and hyperactive reflexes. Laboratory testing reveals a low TSH level, elevated free T3 and free T4, and high uptake on a radioactive iodine uptake scan. Which one of the following is the most likely diagnosis? (check one) A. Postpartum thyroiditis B. Silent thyroiditis C. Subacute thyroiditis D. Graves’ disease E. Exogenous thyroid ingestion A 42-year-old male presents with anterior neck pain. His thyroid gland is markedly tender on examination, but there is no overlying erythema. He also has a bilateral hand tremor. His erythrocyte sedimentation rate is 82 mm/hr. (N 1-13) and his WBC count is 11,500/mm3 (N 4300-10,800). His free T4 is elevated, TSH is suppressed, and radioactive iodine uptake is abnormally low. Which one of the following treatment options would be most helpful at this time? (check one) A. Levothyroxine (Synthroid) and NSAIDs B. Propylthiouracil C. Prednisone D. Nafcillin E. Thyroidectomy A 57-year-old female with a past medical history significant for well-controlled type 2 diabetes mellitus, hypertension, and hyperthyroidism presents to your office with a chief complaint of a sore throat and a fever to 101.5°F at home. She has had chills and night sweats but has not had a cough, chest pain, or abdominal pain. Physical Findings General… Ill appearing HEENT… Diffuse tender anterior cervical adenopathy; thyroid nontender; oropharynx erythematous with some pus on her tonsils Cardiovascular… Tachycardia without murmur Skin… mild jaundice Laboratory Findings Rapid strep test… Negative Total WBC count… 3000/mm3 (N 4500-11,000) and absolute neutrophil count 0 Total bilirubin… 5 mg/dL (N 0-1.0) Alkaline phosphatase… 151 U/L (N 38-126) Which one of the following medications is most likely to cause these laboratory abnormalities? (check one) A. Amlodipine (Norvasc) B. Aspirin C. Metformin (Glucophage) D. Methimazole (Tapazole) In a patient with symptoms of thyrotoxicosis and elevated free thyroxine (T4 ), the presence of thyroid TSH receptor site antibodies would indicate which one of the following as the cause of thyroid gland enlargement? (check one) A. Toxic multinodular goiter B. Toxic adenoma C. Hashimoto's (lymphadenoid) thyroiditis D. Subacute (giant cell) thyroiditis E. Graves' disease A 35-year-old nulligravida sees you for preconception counseling. She has hypothyroidism treated with levothyroxine (Synthroid), and her most recent TSH level was in the therapeutic range. She has no symptoms of hypothyroidism. Which one of the following is the patient most likely to require if she becomes pregnant? (check one) A. A decreased dosage of levothyroxine B. An increased dosage of levothyroxine C. The addition of liothyronine (Cytomel) D. Substitution of desiccated thyroid hormone preparation Which one of the following conditions can affect hemoglobin A1c levels? (check one) A. Heart failure B. Chronic hemolytic anemia C. COPD D. Hypothyroidism A 50-year-old female sees you for follow-up of uncontrolled hypertension. Her recent blood pressure measurements average >175/105 mm Hg. The patient has diabetes mellitus and a BMI of 32.3 kg/m2. Physical findings are otherwise noncontributory. Recent laboratory studies include three different potassium levels <3.5 mEq/L (N 3.5-5.0) despite increasing dosages of oral potassium supplements, with the dosage now at 100 mEq daily. Which one of the following would be most appropriate at this point? (check one) A. Measurement of peripheral aldosterone concentration and peripheral renin activity B. CT of the abdomen C. Renal CT angiography D. An aldosterone suppression test You are asked to medically manage a 66-year-old patient who is scheduled for an elective cholecystectomy. He is also being treated for panhypopituitarism secondary to a pituitary macroadenoma resection many years ago. His medications include levothyroxine (Synthroid), 125: g/day; prednisone, 10 mg in the morning and 5 mg in the evening; and fludrocortisone, 10 mg/day. Preoperative orders for this patient should include which one of the following? (check one) A. Normal saline intravenously as a bolus B. ACTH daily while on intravenous fluids C. Hydrocortisone, 25 mg intravenously every 8 hr. D. Levothyroxine, 250 :g intravenously daily In which one of the following patients should a creatine kinase level be obtained to detect Duchenne muscular dystrophy? (check one) A. A 2-month-old male who is unable to roll over from prone to supine B. A 7-month-old male who is unable to get into a sitting position unassisted C. A 15-month-old male who is walking but is unable to stand up from a supine position without support D. A 16-month-old male who is not walking unassisted E. A 6-month-old with high neuromuscular tone on physical examination An 80-year-old female is seen for progressive weakness over the past 8 weeks. She says she now has difficulty with normal activities such as getting out of a chair and brushing her teeth. Her medical problems include hypertension, diabetes mellitus, and hyperlipidemia. Her medications include glipizide (Glucotrol), simvastatin (Zocor), and lisinopril (Prinivil, Zestril). Findings on examination are within normal limits except for diffuse proximal muscle weakness and normal deep tendon reflexes. A CBC, urinalysis, erythrocyte sedimentation rate, TSH level, and serum electrolyte levels are normal. Her blood glucose level is 155 mg/dL, and her creatine kinase level is 1200 U/L (N 40-150). Which one of the following is the most likely diagnosis? (check one) A. Statin-induced myopathy B. Polymyalgia rheumatica C. Guillain-Barré syndrome D. Diabetic ketoacidosis A 45-year-old male with diabetes mellitus returns to your office for follow-up. He is on metformin (Glucophage), 1000 mg/day, as well as atorvastatin (Lipitor), 40 mg daily for hyperlipidemia. There is no diagnosis of hypertension, and his blood pressure at today's visit is 120/70 mm Hg. Laboratory results include a hemoglobin A1c of 6.4% and an LDL-cholesterol level of 105 mg/dL. His urine albumin/creatinine ratio is in the macroalbuminuric range for the first time. Which one of the following would be most appropriate at this point? (check one) A. Renal ultrasonography B. A repeat urine albumin/creatinine ratio C. 24-hour urine for microalbumin D. Increasing the atorvastatin dosage E. Stopping metformin An overweight 11-year-old male with acanthosis nigricans is found to have a fasting plasma glucose level of 175 mg/dL on two occasions. Over the next 6 months, despite reasonable adherence to a diet and exercise regimen, he has pre-prandial and bedtime finger-stick blood glucose levels that average 180 mg/dL. His hemoglobin A1c is 9.0%. Which one of the following oral agents would be most appropriate at this time? (check one) A. Metformin (Glucophage) B. Glyburide (DiaBeta) C. Sitagliptin (Januvia) D. Pioglitazone (Actos) E. Acarbose (Precose) Which one of the following is the major mechanism of action of metformin (Glucophage)? (check one) A. Stimulation of pancreatic insulin release B. Inhibition of glucose production by the liver C. Inhibition of carbohydrate absorption in the small intestine D. Improved insulin sensitivity of skeletal muscle Which one of the following classes of diabetes medications acts primarily by stimulating pancreatic insulin secretion? (check one) A. Biguanides, such as metformin (Glucophage) B. Thiazolidinediones, such as pioglitazone (Actos) C. DPP-4 inhibitors, such as sitagliptin (Januvia) D. Sulfonylureas, such as glipizide (Glucotrol) E. Amylin analogs, such as pramlintide (Symlin) Which one of the following injection sites for insulin administration is best for preventing hypoglycemia in a 14-year-old male with diabetes mellitus who wishes to participate in track and field running events? (check one) A. Arm B. Abdomen C. Hip D. Calf E. Thigh A 35-year-old white male who has had diabetes mellitus for 20 years begins having episodes of hypoglycemia. He was previously stable and well controlled and has not recently changed his diet or insulin regimen. Which one of the following is the most likely cause of the hypoglycemia? (check one) A. Spontaneous improvement of β-cell function B. Renal disease C. Reduced physical activity D. Insulin antibodies Which one of the following should be monitored during testosterone replacement therapy? (check one) A. Patient Health Questionnaire 9 (PHQ-9) scores B. Fasting glucose levels C. Fasting lipid profiles D. Hematocrit E. Overnight polysomnography Which one of the following is associated with testosterone supplementation in men with hypogonadism? (check one) A. Muscle wasting B. Polycythemia C. Osteoporosis D. An increased risk of benign prostatic hypertrophy A hemoglobin A1c of 7.0% would correspond to which one of the following mean (average) plasma glucose levels? (check one) A. 126 mg/dL B. 154 mg/dL C. 183 mg/dL D. 212 mg/dL E. 240 mg/dL A 62-year-old female with type 2 diabetes mellitus routinely has fasting blood glucose levels in the 80-100 mg/dL range and her hemoglobin A1c level is 7.8%. She has been diligently monitoring her blood glucose levels and all are acceptable with the exception of elevated bedtime readings. She currently is on insulin glargine (Lantus), 18 U at night. Which one of the following changes would be most appropriate for this patient? (check one) A. Adding rapid-acting insulin at breakfast B. Adding rapid-acting insulin at lunch C. Adding rapid-acting insulin at dinner D. Increasing the nightly insulin glargine dose E. Increasing the insulin glargine dosage and giving two-thirds in the morning and one-third at night A 58-year-old male delivery truck driver is diagnosed with type 2 diabetes mellitus and after several months of working on lifestyle modification his hemoglobin A1c is 8.0%. You suggest it is time to start a medication to help control his condition but he is very worried about having a "low sugar reaction" that would prevent him from driving. He is on no other medications at this time. His only other health problem is long-standing controlled hypertension. His BMI is 33.1 kg/m2 and his serum creatinine level is 1.2 mg/dL (N 0.6-1.5). Which one of the following medications would be least likely to cause hypoglycemia in this patient? (check one) A. Canagliflozin (Invokana) B. Glimepiride (Amaryl) C. Glipizide (Glucotrol) D. Insulin glargine (Lantus) E. Metformin (Glucophage) Which one of the following is more likely to occur with glipizide (Glucotrol) than with metformin (Glucophage)? (check one) A. Lactic acidosis B. Hypoglycemia C. Weight loss D. Gastrointestinal distress Which one of the following findings on examination of the head, oral cavity, and neck is associated with diabetes mellitus? (check one) A. Parotid enlargement B. Tooth erosion C. Diffuse melanin pigmentation D. Cobblestone oral mucosa E. Painful oral ulcers A 42-year-old male has symptoms of hypogonadism. Which one of the following should be ordered first? (check one) A. Early morning total serum testosterone B. Early morning total and free serum testosterone C. Early morning total and late afternoon total serum testosterone D. Early morning and late afternoon free serum testosterone E. Early morning and late afternoon total and free serum testosterone Which one of the following, when confirmed with a repeat test, meets the diagnostic criteria for diabetes mellitus? (check one) A. A fasting blood glucose level of 120 mg/dL B. A 2-hour value of 180 mg/dL on an oral glucose tolerance test C. A random glucose level of 180 mg/dL in a patient with symptoms of diabetes mellitus D. A positive urine dipstick for glucose E. A hemoglobin A1c of 7.0% Which one of the following is the best diagnostic test for vitamin D deficiency? (check one) A. Ionized calcium B. Serum phosphorus C. 24-hour urine for calcium D. 1,25-hydroxyvitamin D E. 25-hydroxyvitamin D A critically ill adult male is admitted to the intensive-care unit because of sepsis. He has no history of diabetes mellitus, but his glucose level on admission is 215 mg/dL and insulin therapy is ordered. Which one of the following is the most appropriate target glucose range for this patient? (check one) A. 80-120 mg/dL B. 100-140 mg/dL C. 120-160 mg/dL D. 140-180 mg/dL E. 160-200 mg/dL In patients with type 2 diabetes mellitus, intensive glycemic control has not been shown to be beneficial for which one of the following diabetic complications? (check one) A. Peripheral neuropathy B. Foot infections C. Cardiovascular disease D. Proliferative retinopathy E. Nephropathy A 36-year-old female sees you for a 6-week postpartum visit. Her pregnancy was complicated by gestational diabetes mellitus. Her BMI at this visit is 33.0 kg/m2 and she has a family history of diabetes mellitus. This patient's greatest risk factor for developing type 2 diabetes mellitus is her: (check one) A. age B. obesity C. history of a completed pregnancy D. history of gestational diabetes E. family history of diabetes A 36-year-old female consults you because of concerns about "fatigue." After carefully reviewing her history and performing a physical examination, which one of the following would be LEAST valuable in assessing this patient? (check one) A. A baseline serum cortisol level B. An erythrocyte sedimentation rate C. A complete metabolic panel D. A TSH level E. A pregnancy test A 22-year-old male presents to your office for evaluation of fatigue, poor appetite, and nausea. He states that when he stands too long he often gets dizzy but this is relieved by sitting. His symptoms have been gradually getting worse over the past year. His vital signs are normal but he is found to be orthostatic. A physical examination is unremarkable except for hyperpigmentation in his palmar creases and around his nipples. A basic metabolic panel is notable for a sodium level of 131 mEq/L (N 135-145) and a potassium level of 5.1 mEq/L (N 3.5-5.0). Which one of the following is the most likely cause of this patient's symptoms? (check one) A. Addison's disease B. Cushing syndrome C. Neurally mediated hypotension D. Postural orthostatic hypotension and tachycardia syndrome E. Hypothyroidism Complications of hypoparathyroidism include (check one) A. Somnolence B. Low vitamin D C. Muscle flaccidity D. Hyperkalemia E. Refractory heart failure A 61-year-old female is found to have a serum calcium level of 11.6 mg/dL (N 8.6-10.2) on routine laboratory screening. To confirm the hypercalcemia you order an ionized calcium level, which is 1.49 mmol/L (N 1.14-1.32). Additional testing reveals an intact parathyroid hormone level of 126 pg/mL (N 15-75) and a urine calcium excretion of 386 mg/24 hr. (N 100-300). Which one of the following is the most likely cause of the patient's hypercalcemia? (check one) A. Primary hyperparathyroidism B. Malignancy C. Familial hypocalciuric hypercalcemia D. Hypoparathyroidism E. Hyperthyroidism A 14-year-old female sees you for follow-up after hypercalcemia is found on a chemistry profile obtained during a 5-day episode of vomiting and diarrhea. She is now asymptomatic, but her serum calcium level at this visit is 11.0 mg/dL (N 8.5-10.5). Her aunt underwent unsuccessful parathyroid surgery for hypercalcemia a few years ago. Which one of the following laboratory findings would suggest a diagnosis other than primary hyperparathyroidism? (check one) A. Low 24-hour urine calcium B. Decreased serum phosphate C. High-normal to increased serum chloride D. Elevated alkaline phosphatase E. Elevated parathyroid hormone A 59-year-old male reports nausea, vomiting, and progressive fatigue for the past few months. At his last visit, 6 months ago, his blood pressure was poorly controlled and hydrochlorothiazide was added to his β-blocker therapy. At this visit he appears moderately dehydrated on examination. Laboratory testing reveals a serum calcium level of 12.5 mg/dL (N 8.0-10.0), a BUN level of 36 mg/dL (N 6-20), and a creatinine level of 2.2 mg/dL (N 0.6-1.1). A CBC, albumin level, and electrolyte levels are normal. His intact parathyroid hormone level is reported a few days later, and is 60 pg/mL (N 10-65). What is the most likely cause of his hypercalcemia? (check one) A. Renal failure B. Hyperparathyroidism C. Milk alkali syndrome D. Sarcoidosis A 47-year-old postmenopausal female falls while carrying groceries into her house and sustains a right distal radial fracture. A chemistry panel reveals a calcium level of 11.2 mg/dL (N 8.6-10.6) and further evaluation leads to a diagnosis of primary hyperparathyroidism. Which one of the following is the best course of treatment for this patient? (check one) A. Estrogen replacement therapy B. Long-term bisphosphonate therapy C. Daily furosemide treatment with increased oral fluids D. Elimination of calcium and vitamin D from the diet E. Referral to a surgeon for consideration of parathyroidectomy A 68-year-old female presents with a several-month history of weight loss, fatigue, decreased appetite, and vague abdominal pain. The most appropriate initial test to rule out adrenal insufficiency is: (check one) A. Morning serum cortisol B. A cosyntropin (ACTH) stimulation test C. MRI D. An insulin tolerance test E. A metyrapone test Which one of the following is diagnostic for type 2 diabetes mellitus? (check one) A. A fasting plasma glucose level ≥126 mg/dL on two separate occasions B. An oral glucose tolerance test (75-g load) with a 2-hour glucose level ≥160 mg/dL C. A random blood glucose level ≥200 mg/dL on two occasions in an asymptomatic person D. A hemoglobin A 1c ≥6.0% on two separate occasions A 47-year-old male with chronic kidney disease is being treated with epoetin alfa (Procrit). His hemoglobin level is 11.3 g/dL (N 13.0-18.0). Which one of the following would be most appropriate with regard to his epoetin alfa regimen? (check one) A. Increase the dosage until the hemoglobin level is >12.0 g/dL B. Increase the frequency of injections, using the same dose C. Decrease the frequency of injections, using the same dose D. Continue the current regimen An incidental 2-cm adrenal nodule is discovered on renal CT performed to evaluate hematuria in a 57-year-old female with flank pain. She has no past medical history of palpitations, headache, hirsutism, sweating, osteoporosis, diabetes mellitus, or hypertension. A physical examination is normal, with the exception of a blood pressure of 144/86 mm Hg. Laboratory evaluation reveals a serum sodium level of 140 mmol/L (N 135-145) and a serum potassium level of 3.8 mmol/L (N 3.5-5.0). What is the most appropriate next step in the evaluation of this patient? (check one) A. Repeat CT in 12 months B. Evaluation for adrenal hormonal secretion C. Fine-needle aspiration of the nodule D. MRI of the abdomen E. Referral to a general surgeon for exploratory laparotomy A 20-year-old college wrestler is seen for an examination prior to the wrestling season. He tells you that some friends have told him he should start taking dehydroepiandrosterone (DHEA), and he asks for your advice. Which one of the following is true about the effects of this drug? (check one) A. It enhances performance but not muscle strength B. It enhances muscle strength but not performance C. It enhances both performance and muscle strength D. It does not enhance either performance or muscle strength A 36-year-old female presents with a several-week history of polyuria and intense thirst. She currently takes no medications. On examination her blood pressure and pulse rate are normal, and she is clinically euvolemic. Laboratory tests, including serum electrolyte levels, renal function tests, and plasma glucose, are all normal. A urinalysis is significant only for low specific gravity. Her 24-hour urine output is >5 L with low urine osmolality. The most likely cause of this patient's condition is a deficiency of: (check one) A. angiotensin II B. aldosterone C. renin D. insulin E. arginine vasopressin [Show More]
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