1st Endocrine USMLE

A 40-year-old female presents with altered mental status and confusion. Last year, she was diagnosed with rheumatoid arthritis, for which she is currently using indomethacin and methotrexate. Her temperature is 37.0C (98.6F), pulse is 75/min, blood pressure is 110/70, and respirations are 15/min. She is disoriented and irritable. Mucus membranes are moist. There is no jugular venous distention. Lungs are clear to auscultation. Abdomen is soft, nontender and not distended. There is no peripheral edema. Serum chemistry reveals: Sodium 122 mEq/L Potassium 3.7 mEq/L Bicarbonate 22 mEq/L Blood glucose 90 mg/dL BUN 9.0 mg/dL Uric acid 3.0 mg/dL Serum osmolality is 265mOsm/kg, while urine osmolality is 500 mOsm/kg. What is the most likely cause of this patient's hyponatremia?

A 50-year-old male presents for the evaluation of polyuria and polydipsia of two months duration. He also complains of weakness and fatigue. He had one episode of paralysis that resolved on its own. He has a 20 pack-year history of smoking. He does not drink alcohol. His past medical and family histories are not significant His pulse is 78/min, blood pressure is 150/96 mmHg and temperature is 37C (98.6 F). The rest of his examination, including the neurological examination, is unremarkable. Laboratory studies show: Plasma sodium 145 mEq/L Potassium 24 mEq/L Serum creatinine 0.8 mg/dl Plasma renin activity low Plasma aldosterone concentration high Which of the following is the most likely diagnosis?

65-year-old Caucasian male comes to the office because of bilateral foot pain, which is present at rest and worsens at night. He has been having this symptom for the past few months. Other accompanying symptoms are hyperesthesia and paresthesia in both lower limbs. His medical problems include diabetes for the past twenty years. His daily medication is insulin. Physical examination reveals bilateral loss of ankle reflexes, loss of vibratory sensation and altered proprioception below the knees. His HbA1c level is 9%. Urine is positive for microalbuminuria. Which of the following is the most appropriate treatment for his leg pain?

A 49-year-old African-American male comes to the office and complains of headaches which have been worsening for the last three months. His other complaints include diffuse joint pains, pain on the lateral half of his right hand, difficulty getting his wedding ring out due to finger swelling, and difficulty holding and gripping objects with his right hand. His past medical history is significant for hypertension, which has not been controlled well despite compliance with medications, very low salt diet, and regular exercise. His current medications are amlodipine, lisinopril, and hydrochlorothiazide. His blood pressure is 146/98 mmHg, pulse is 90/min, temperature is 36.7C (98F) and respirations are 14/min. His facial features appear coarse when compared to his driver's license photo, which was taken three years ago. His palms are sweaty and have a doughy feel. His skin is oily. There are multiple skin tags, particularly around his neck area. Hand examination reveals positive Tinel's and Phalen's sign. Which of the following will be the most helpful in confirming the clinical diagnosis?

A 55-year-old African-American male comes to the office for a routine follow-up visit. His past medical history is significant for type 2 diabetes mellitus (OM), hypertension for the last 5 years, and an acute myocardial infarction 2 years ago. His mother died of a heart attack at the age of 72 years, and his father died in a motor vehicle accident at the age of 42 years. He has no siblings. He is currently on glyburide, captopril and baby aspirin. He is very compliant with his diet and medication. His glycemic control was very good until a few months ago, when he noticed that his blood sugar levels were running high. This morning, his finger stick reading was 200 mg/dl. He weighs 188 lbs and is 5'8" tall. His physical examination is otherwise unremarkable. His blood work done three days ago showed blood urea nitrogen of 14 mg/dl and a creatinine level of 1.0 mg/dl. His HBA1c one month ago was 8.0%. Which of the following is the most appropriate next step in management?

A 55-year-old Caucasian male presents to the office for a routine check-up. He has no present complaints. His past medical history is significant for a long history of hypertension. He does not smoke or consume alcohol. His current medications are enalapril and hydrochlorothiazide. His blood pressure is 140/90 mm Hg and heart rate is 80/min. Physical examination reveals a moderately overweight man (BMI = 27 kg/m2) with a waist circumference of 41 inches. The laboratory studies show: Fasting blood glucose 112 mg/dl Total cholesterol 220 mg/dl LDL cholesterol 140 mg/dl Triglycerides 240 mg/dl Which of the following is the most important pathogenic factor for this patient's condition?

A 24-year-old Caucasian female comes to the outpatient clinic and complains of heat intolerance and increased appetite. Her past medical history is insignificant. She denies use of over-the-counter medications. Her pulse is 110/min and regular, temperature is 37.2C (99F), and respirations are 14/min. Swelling is noted in the front of her neck, which moves with deglutition. Lab studies show: Total T4 Increased Free T4 Increased TSH Decreased Radioactive iodine uptake is decreased. The thyroid scan shows very low uptake of radioiodine. What is the most likely diagnosis?

A 54-year-old male comes to the office for follow-up care of his foot ulcer. He has no complaints regarding the ulcer, but he has recently become polyuric and polydipsic. Fa sting blood work reveals elevated glucose levels. He is prescribed oral hypoglycemics, and counseled on self-monitoring at home. On his next follow-up visit, the patient proudly states that he has been "very compliant" with his medications, and that his glucose levels are "always well-controlled." Which of the following is the best way to determine whether this patient is telling the truth?

A 48-year-old white male complains of generalized bone pain after undergoing bowel surgery for inflammatory bowel disease. His pain is more severe at the lower spine, pelvis, and lower extremities. Examination shows tenderness over the lower spine, pelvis, and lower extremities. Proximal muscle weakness is noted. X-rays of the lumbar spine show decreased bone density with blurring of the spine. X-rays of the femoral neck show pseudofractures, bilaterally. Which of the following lab abnormalities is consistent with this patient's diagnosis?

A 24-year-old white female is brought to the emergency department (ED) by her mother due to altered mental status. According to her mother, she suffered from viral gastroenteritis 4 days ago. Since then, she has been on oral fluids. Over the past 2 days, her condition had been deteriorating, but she kept refusing admission to the hospital. Her past history is not significant, except for excessive thirst, water intake and weight loss over the past two months. Her blood pressure is 100/56 mm Hg, pulse is 120/min (regular and weak), temperature is 37.2C (99.F), and respirations are 28/min (rapid and deep). Pulse oximetry is 94% on room air. She is arousable and moves all her extremities. Her mucous membranes are very dry. Her neck is supple. The chest is clear on auscultation. Which of the following is the most appropriate next step in management?

A 38-year-old Mexican male presents to the emergency department with a history of weight loss, fever, cough with sputum, nausea, abdominal pain, and postural dizziness for the last three months. Adrenal insufficiency is suspected, and cosyntropin (synthetic ACTH) stimulation test is performed. The rise of serum cortisol following an injection of cosyntropin is grossly subnormal. CT scan of the abdomen shows calcification of both adrenal glands. What is the most likely cause of this patient's adrenocortical insufficiency?

A 60-year-old male comes to the office due to edema of his face and ankles of two weeks duration. He denies any chest pain or breathlessness. He is a known diabetic for the past 15 years. His diabetes is being managed with exercise, dietary modification and glyburide. His glycosylated hemoglobin (HbA1C) level one month ago was 7.5%. His temperature is 37.0C (98.6F), pulse is 75/min, blood pressure is 146/87 mm Hg, and respirations are 15/min. Examination is unremarkable, except for bilateral pitting edema around the ankles and periorbital edema. Lab results show: Serum sodium 140 mEq/L Potassium 4.3 mEq/L Bicarbonate 20 mEq/L Blood glucose120 mg/dl Blood urea nitrogen 37 mg/dl Serum creatinine 24 mg/dl Total cholesterol 300 mg/dl EKG is normal. 24-hour urine collection shows 3.7 g protein/day. To alter the course of this patient's diabeticnephropathy, what is the most appropriate next step in management?

A 17-year-old white female comes to the office for the evaluation of fatigue which has been present for the past 4 months. Her past medical history is insignificant. She denies the use of any drugs. Her pulse is 74/min, blood pressure is 110/70 mm Hg, and temperature is 36.7C (98.0F). Physical examination shows scars on the dorsum of her hands and dental erosions. Laboratory studies show: Plasma sodium 139 mEq/L Serum potassium 2.3 mEq/L Bicarbonate 40 mEq/L Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L). Based on these findings, what is the most likely diagnosis?

A 21 -year-old female has a several month history of easy fatigability and palpitations. She also complains of excessive sweating. She follows a strict, low calorie diet in order to lose weight. Her blood pressure is 120/70 mmHg and her heart rate is 100/min. Her BMI is 19kg/m2 Thyroid function testing reveals the following findings: TSH decreased Total T4 high Total T3 high Radioiodine uptake is diffusely decreased over the thyroid gland. Which of the following is the most likely pathologic finding on biopsy of this woman's thyroid gland?

A 60-year-old Caucasian male is brought to the emergency department by his daughter due to a 2-day history of confusion and lethargy. According to his daughter, he had been complaining of fatigue, anorexia, polyuria and constipation for the last several weeks. He smokes two packs of cigarettes daily, and consumes alcohol occasionally. His blood pressure is 130/90 mmHg and heart rate is 90/min. Physical examination reveals a somnolent patient who is not oriented in time. His lab values are: Serum Na 140 mEq/L Serum K 4.0 mEq/L Serum chloride 100 mEq/L Serum bicarbonate 22 mEq/L Serum creatinine 1.6 mg/dl Serum calcium 13.4 mg/dl Serum phosphorus 2.2 mg/dl Blood glucose 1 00 mg/dl Alkaline phosphatase 80 U/L Chest x-ray demonstrates a right middle lobe mass and perihilar adenopathy. What is the most probable cause of this patient's symptoms?

A 45-year-old white male patient presents for the evaluation of high blood pressure. He also complains of polyuria, polydipsia and fatigue. His past medical and family histories are unremarkable. He does not use tobacco, alcohol or drugs. His blood pressure is 180/100mmHg. Physical examination shows no abnormalities. Laboratory studies show low serum potassium and high plasma aldosterone levels. CT scan of the abdomen shows a small, right adrenal mass. Which of the following additional findings is most likely to be present in this patient?

A 51 -year-old female comes to the office for a routine visit. She is apparently healthy and does not have any complaints. Physical examination reveals a thyroid nodule. She is surprised to hear about the nodule and asks, "How often does this happen? What could have caused this?" Which of the following is the most common cause of thyroid nodules?

A 40-year-old white female presents with complaints of heat intolerance, sweating and palpitations. She also reports menstrual irregularities, increased appetite and diarrhea. She has had these symptoms for the past 4 Months. Her pulse is 102/min and regular, blood pressure is 116/80 mm Hg, temperature is 37.2C (99F), and respirations are 14/min. Physical examination reveals a non-tender, diffuse swelling in front of her neck; it moves upwards with deglutition. Her TSH level is 0.05 mU/L. Free T4 and T3 levels are increased. Radioactive iodine uptake at 24 hours is significantly increased. Pregnancy test is negative. Which of the following is the most appropriate long-term treatment modality for this patient? A S

A 56-year-old female is admitted with a diagnosis of chronic renal failure from systemic lupus erythematosus and non-steroidal anti-inflammatory drug use. She has a history of recurrent kidney stones. Laboratory studies show the following: Serum calcium 10.6 mg/dl Serum albumin 3.9 g/L PTH 140 pg/ml Serum phosphorus 3.0 mg/dl Her baseline serum creatinine level ranges from 1.6 to 1.8 mg/dl. Her bone mineral density is measured by DXA scan, revealing a T score of-2.5 at the lumbar spine, which is consistent with osteoporosis. What is the most likely cause of this patient's hypercalcemia?

A 50-year-old Caucasian male comes to the office for the evaluation of polyuria and polydypsia for the last two months. He also complains of weakness and fatigue. He had one episode of transient proximal muscle weakness which lasted 30 minutes. He has a 20-pack year history of smoking. He does not drink alcohol. His past medical and family histories are insignificant. His pulse is 78/min, blood pressure is 150/96 mm Hg and temperature is 36.7C (98F). The rest of the examination, including the neurological examination, is normal. Labs show: Plasma sodium 150 mEq/L Potassium 2.6 mEq/L Serum creatinine 0.8 mg/dL Which of the following is the most appropriate next step in the management of this patient?

A 78-year-old female is being evaluated for recent weight loss and fatigue. Laboratory tests reveal abnormal thyroid function. She begins treatment with a single agent, but soon after is hospitalized with new onset atrial fibrillation and hand tremor. Which of the following treatments had she most likely received?

A 46-year-old male presents with swelling of his face that is especially prominent in the periorbital area. He also complains of bilateral ankle swelling. He denies shortness of breath, fever and discoloration of urine. He is a non-smoker and non-alcoholic. His past medical history is not significant. He is currently not taking any medication. His pulse is 78/min, blood pressure is 130/70mm Hg, respirations are 14/min and temperature is 37.1C (99.0F). Examination shows bilateral pitting ankle edema. Auscultation reveals clear lungs, normal heart sounds, and no murmurs. Dipstick urinalysis is positive for protein. 24-hour urine collection shows proteinuria of 4.6 g/day. Lab studies show: Total serum calcium 7.5 mg/dl Albumin 2.2 g/dl Phosphorus 3.5 mg/dl Magnesium 2.2 mg/dl Creatinine 0.8 mg/dl Which of the following is the most likely cause of his low serum calcium level?

A 55-year-old male presents with complaints of an ulcer over the sole of his right great toe for one week. His medical problems include a ten-year history of hypertension, diabetes and hypercholesterolemia. His current medications are ramipril, aspirin, metformin, glibenclamide and pravastatin. He has a 20-pack year history of smoking and occasionally drinks alcohol. He denies illegal drug use or multiple sexual partners. Which of the following is most likely contributing to the development of his foot ulcer?

A 28-year-old white female presents to the office for the evaluation of goiter. She denies any recent change in appetite or weight, diarrhea, constipation, heat or cold intolerance, dyspnea and hoarseness. Her menses are normal and regular. Examination shows a symmetrically enlarged, non-tender, firm and rubbery thyroid gland. There is no lymphadenopathy. The rest of the physical examination is normal. Laboratory studies reveal an elevated serum TSH level with normal T4 and T3 levels. Serological testing for Hashimoto's thyroiditis is ordered. Which of the following are the most prevalent antibodies in patients with Hashimoto's thyroiditis?

A 23-year-old Caucasian male with muscular weakness, vomiting and abdominal pain is brought to the emergency department. He had a minor respiratory illness 2 days ago. His past medical history is significant for diabetes mellitus, type 1. He admits skipping his insulin shots yesterday and today because he had no appetite. His temperature is 37.8C (100F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 27/min. His oral mucosa is dry. The laboratory values are: Serum sodium 132 mEq/L Serum potassium 5.4 mEq/L Serum calcium 8.9 mEq/L Serum chloride 96 mEq/L Serum bicarbonate 12 mEq/L Blood glucose 470 mg/dl BUN 19 mg/dl Serum creatinine 1.1 mg/dl Which of the following is the most likely cause of the increased potassium level in this patient?

A 45-year-old female comes to the office for the evaluation of excessive hair growth over her face and body. Her hirsutism rapidly developed over a period of 3 months. She underwent bilateral tubal ligation 4 years ago. Her menstrual cycles were regular in the past, but for the last 3 months, she has not had a menstrual period. She denies any hot flashes or vaginal discomfort. On physical examination, her height is 5'2" (169 cm) and weight is 140 lbs (63.5kg). A large amount of coarse terminal hair is noted on her face, chest and lower abdomen. She appears masculine and has an enlarged clitoris. There is significant temporal balding. Which of the following is the most appropriate next step in management?

A 31-year-old Hispanic female presents with palpitations and weight loss. Her past medical history is insignificant. Her family history is unremarkable. She recently moved from South America. She does not smoke cigarettes or drink alcohol. She is married and has three children. Her last delivery was four years ago. Her blood pressure is 140/90 mmHg, pulse is 102/min, temperature is 36.7C (98F) and respirations are 20/min. Her eye examination is unremarkable. Thyroid examination reveals a 2 x 2 cm left-sided thyroid nodule. Her T3 and T 4 are elevated, and TSH is undetectable. Radioactive iodine scan shows uptake only in the left thyroid nodule. Uptake in the rest of the thyroid is markedly reduced. Which of the following is the most likely diagnosis?

A 29-year-old white female presents to the emergency department with nausea, vomiting, severe generalized abdominal pain, and hypotension. She is subsequently admitted to the intensive care unit. Her past medical history is significant for hypothyroidism secondary to Hashimoto's thyroiditis, for which she has been taking levothyroxine. She denies smoking cigarettes, drinking alcohol, and using any intravenous drugs. Her mother also has hypothyroidism. Her blood pressure is 70/50 mm Hg, heart rate is 110/min, temperature is 98.4F (37.0C) and respiratory rate is 24/min. Physical examination reveals dry and pigmented mucous membranes. The skin creases also show increased pigmentation. Lab studies show: Serum chemistry: Serum Na 130 mEq/L Serum K 6.1 mEq/L Chloride 96 mEq/L Bicarbonate 18 mEq/L BUN 33 mg/dL Serum creatinine 1.3 mg/dL Blood glucose 56 mg/dL CBC: Hemoglobin 10.8 g/L Platelets 300,000/mm3 Leukocyte count 6,500/mm3 Neutrophils 70% Eosinophils 10% Lymphocytes 20% The random serum cortisol level is 3.2 mcg/dL (normal= 5 to 25 mcg/dL), and ACTH level is 142 pg/mL (normal= 9 to 52 pg/mL). What is the most likely involved pathophysiologic mechanism of this patient's disorder?

A 40-year-old male patient presents with a thyroid nodule. His other complaints are episodes of palpitations, anxiety and sweating. He denies heat intolerance. His weight and appetite are normal. He has a family history of thyroid cancer. His pulse is 80/min, and blood pressure is 160/ 100 mm Hg. Examination of the neck shows a 4-cm, hard, non-tender thyroid nodule. The urinalysis, serum sodium, serum potassium, serum calcium, serum creatinine, serum PTH, TSH, T3 and T 4 levels, and the EKG are all normal. The serum calcitonin level is elevated. The urinary levels of metanephrine and norepinephrine are increased as well. FNA biopsy of the thyroid nodule shows malignant cells. Genetic testing shows a mutation in the RETproto oncogene. Which of the following abnormalities is also present in most patients suffering from this disorder?

A 60-year-old female presents with transient loss of consciousness. She appears lethargic and confused. She also complains of hemoptysis and weight loss of 10 lbs (4 .5kg) over a period of 2 months. She has smoked one pack of cigarettes daily for the last 40 years. Her temperature is 37.0C (98.6 F), pulse is 75/min, blood pressure is 110/70, and respirations are 16/min. Her mucus membranes are moist. There is no jugular venous distention. Her neurological examination is nonfocal, and cardiovascular examination is unrevealing. There is no ankle edema or ascites. Serum studies show: Sodium 115 mEq/L Potassium 3.7 mEq/L Bicarbonate 22 mEq/L Blood glucose 100 mg/dl BUN 10.0 mg/dl Serum osmolality is 250 mOsm/Kg, and urine osmolality is 500 mOsm/Kg. Urine sodium concentration is 40 mEq/L. Chest x-ray shows a mass in the right hilar region. What is the most appropriate next step in the management of this patient?

A 36-year-old male comes to the office for the evaluation of fatigue and weakness for the last several weeks. He denies any change in appetite, change in weight, heat or cold intolerance, nausea, vomiting and constipation. He cannot recall any recent stressful events. His past medical and family histories are unremarkable. He does not have any medications. His pulse is 76/min, blood pressure is 120/70 mm Hg, respirations are 14/min, and temperature is 36.7C (98F). He is well-oriented to time, place and person. His neurological examination is nonfocal; the deep tendon reflexes are normal. Lab tests show: Hematocrit 43% WBC count 6,000/microl Platelet count 200,000/microl Serum calcium 11 mg/dl Serum albumin 4.5 g/dl 24-hour urinary calcium 200 mg Which of the following is the most likely cause of his symptoms?

A 63-year-old white female presents with a thyroid nodule. She denies any weight loss, change in appetite, diarrhea, heat or cold intolerance, menstrual irregularities, hoarseness and dyspnea. Her past medical history is unremarkable. There is no family history of thyroid cancer. She does not take any medications. Physical examination shows a 4-5 cm, fixed, hard, and non-tender thyroid nodule. There is cervical lymphadenopathy. Her serum TSH level is normal. Fine needle aspiration (FNA) of the thyroid shows malignant cells. Which of the following is the most likely expected pathology on FNA?

A 36-year-old female presents with headaches and visual problems. She also complains of palpitations, heat intolerance and weight loss. Her past medical history is unremarkable. She is currently on no medications. Her blood pressure is 130/60 mmHg, heart rate is 100/min and regular, and weight is 152 lb (weight one year ago was 170 lb). Physical examination reveals a symmetrically enlarged thyroid gland without any tenderness. Auscultation of the chest reveals tachycardia. She has bitemporal hemianopsia on confrontation. The rest of the physical examination is unremarkable. Her lab investigations show: Serum T3 222 ng/ml Serum T 4 13.9 mcg/dl Serum TSH 7.9 IU/ml Alpha subunit level elevated Which of the following is the most likely diagnosis?

A 40-year-old African American female comes to the office for a routine medical check-up. She has no complaints. She has twenty pack-year smoking history but she stopped smoking one year ago. Her mother and one maternal uncle have diabetes. Her height is 5'7" inches, and weight is 150 lbs. Her blood pressure is 122/80 mmHg, pulse is 80/min, respirations are 14/min and temperature is 37C (98F). She agrees to have diabetes mellitus screening. Her plasma glucose level after an overnight fast is 130 mg/dl. What is the most appropriate next step in the management of this patient?

A 35-year-old male presents with complaints of weakness and fatigue of one year's duration. He is anorexic and has lost interest in all his activities. He also complains of cold intolerance and constipation. His blood pressure is 98/72 mm Hg, temperature is 37.1C (99F), respirations are 14/min, and pulse is 50/min. His skin is dry and rough, nails are brittle, and hair is thin. There is no hyperpigmentation of the skin. Delayed deep tendon reflexes are noted on neurological examination. Lab studies show: Hemoglobin 10.2 g/dL WBC count 5,000/micro-L Neutrophils 45% Monocytes 5% Eosinophils 10% Basophils 1% Lymphocytes 40% Serum sodium 135 mEq/L Serum potassium 4.0 mEq/L Which of the following is most consistent with this patient's findings?

A 22-year-old female presents with complaints of heat intolerance, sweating and palpitations. She also reports menstrual irregularities, increased appetite and diarrhea. Her pulse is 102/min and regular, blood pressure is 116/80 mm Hg, temperature is 37.2C (99F), and respirations are 14/min. Physical examination reveals a diffusely enlarged, nontender thyroid gland. TSH level is 0.05 mU/L. Free T4 and T3 levels are elevated. Radioactive iodine uptake at 24 hours is 50 percent. Thyroid stimulating immunoglobulins are present. She is started on propylthiouracil 300 mg daily in three divided doses. After two weeks, she returns and complains of a sore throat. Her pulse is 98/min and regular, temperature is 38.6C (101.5F), blood pressure is 115/76 mm Hg, and respirations are 15/min. The soft palate, pharynx, and tonsils are red and swollen. What is the most appropriate next step in the management of this patient?

A 60-year-old male is admitted to the hospital because of right lower lobe pneumonia. His medical history is significant for hypertension, diabetes mellitus, severe degenerative disease of the spine, and longstanding lower back pain. He is a chronic smoker with a 40-pack year smoking history. During his hospitalization, the laboratory report shows decreased serum calcium levels and increased phosphate levels. Further evaluation reveals increased serum intact parathyroid hormone levels. Which of the following medical conditions is most likely responsible for this patient's abnormal lab findings?

A 43-year-old female presents to the physician's office with muscle cramps, polydipsia and polyuria. She has no other medical problems, and does not take any medications. She does not use tobacco, alcohol or drugs. Her father died from alcoholic liver disease at age 50. Her pulse is 75/min, respirations are 13/min, blood pressure is 160/100 mm Hg, and temperature is 37C (98.6F). Laboratory studies show: Blood glucose 115 mg/dl Serum sodium 142 mEq/L Serum potassium 2.7 mEq/L Plasma renin activity is low. What is the most likely diagnosis?

A 19-year-old football linebacker is admitted following a motor vehicle accident. He had an extensive cerebral bleed, which led to a deep coma. He also has fractures of the C4 vertebra, pelvis, and right femur. Following admission, he is intubated and central lines are placed. During the next few days, he develops acute renal failure due to rhabdomyolysis. While he is recovering from acute renal failure, he is found to have a serum calcium level of 12.1 mg/dl. Other investigations are: Serum albumin 3.0 g/dl Serum creatinine 2.8 mg/dl Serum phosphorus 3.8 mg/dl Blood glucose 108 mg/dl PTH 9 pg/ml PTHrP undetectable 1, 25-dihyroxy vitamin D 19 pg/ml (normal 20-60 kg/ml) What is the most likely cause of this patient's hypercalcemia?

A 35-year-old female presents to the emergency department with a 30-minute history of severe headache, palpitations, abdominal pain, nausea, and vomiting. She had similar episodes twice during the last month, but those were not so severe and resolved spontaneously in 30-40 minutes. She visited a doctor recently, and hypertension with elevated urinary vanillylmandelic acid level was diagnosed. She is not taking anymedications, and denies substance abuse. Her blood pressure is 200/130 mmHg and heart rate is 130/min. She appears frightened. Physical examination reveals hand tremors and excessive sweating. Slow intravenous infusion of propranolol is started while waiting for the routine labs. What is the most probable reaction to the treatment given to the patient?

A 65-year-old male comes to the office and complains of nausea and early satiety for the past several months. His other complaints are anorexia and abdominal bloating. He denies any heartburn or epigastric pain. He has diabetes, and has been taking insulin for the last fifteen 15 years. His blood glucose readings using the home blood glucose monitor range between 40 to 400 mg/dl. Most of the low blood glucose readings occur after meals. Which of the following is the most appropriate management of this patient's symptoms?

A 27-year-old Caucasian male is diagnosed with medullary thyroid carcinoma that is non-resectable. His past medical history is insignificant. He does not smoke or consume alcohol. His family history is significant for thyroid cancer and pheochromocytoma in his father. Which of the following tests could have been most effective in preventing this patient's non-resectable cancer?

A 35-year-old male presents to the family physician for bilateral gynecomastia. He observed a progressive increase in his breast size starting 6 months ago. He is sexually active and denies any drug use. Physical examination reveals bilateral gynecomastia and tenderness. The genito-urinary examination shows a 1 cm nodule in the right testis. Otherwise, the examination is within normal limits. The laboratory report shows: LH 3 U/L, FSH 2 U/L, testosterone 270 ng/dL (Normal 3-10 ng/dL), estradiol 115 pg/mL (Normal 20-60 pg/mL), beta HCG undetectable, AFP undetectable. Which is the most likely diagnosis?

A 35-year-old Caucasian male presents with weakness, fatigue, and weight loss over the past year. He is anorexic and has lost interest in all his activities. His temperature is 37.1C (99F), pulse is 84/min, blood pressure is 101/72 mm Hg, and respirations are 14/min. On physical examination, he does not appear to be in acute distress. Dark brown pigmentation is present on his skin creases and oral cavity mucous membranes. Laboratory studies show: Hemoglobin 10.3 g/dL WBC count 3,000/micro-L Neutrophils 60% Monocytes 5% Eosinophils 10% Basophils 1% Lymphocytes 24% Serum sodium 130 meq/L Serum potassium 5.5 meq/L Chest x-ray and PPD tests are normal. What is the most appropriate next step in the management of this patient?

A 56-year-old female comes to the office and complains of general malaise and headaches. Her other symptoms are episodic palpitations, throbbing headaches and diaphoresis. She feels "very anxious all the time." Her past medical history is unremarkable. Her deceased sister had very high blood pressure. Her blood pressure is 230/110 mm Hg and pulse is 110/min. Initial laboratory studies reveal: WBC 7,000/cmm Hb 11.2 g/L Platelets 325,000/cmm Calcium 11.9 mg/dl What is the best next step in the evaluation of this patient?

A 39-year-old woman comes to the physician because of a "pins and needles" sensation around her mouth for the last 2-3 weeks. She gets similar sensations in her feet sometimes, along with muscle cramps, especially at the end of the day. She has no similar episodes in the past and has always been healthy. She works as a waitress and has "clean habits." Her family history is not significant. She is currently not taking any medications, and is allergic to penicillin. Her vital signs are normal. Examination is unremarkable. The patient's labs reveal: CBC: Hb 12.4 g/dl WBC 6,000/cmm Serum: Serum Na 140 mEq/L Serum K 4.0 mEq/L Chloride 100 mEq/L Bicarbonate 24 mEq/L BUN 10 mg/dl Serum creatinine 0.8 mg/dl Glucose 100 mg/dl Calcium 6.5 mg/dl Phosphorus, inorganic 5.8 mg/dl Protein: Total 7.0 g/dl Albumin 3.8 g/dl Globulins 3.0 g/dl Which of the following is the most likely cause of her condition?

A 45-year-old male, found unconscious, is brought to the emergency room. His airway is maintained, and oxygen is administered. His temperature is 39.0C (102.5F), pulse is 102/min, blood pressure is 90/65 mm of Hg and respirations are 23/min. Intravenous access is secured and blood and urine samples are drawn. Lab results are as follows: Sodium 134 mEq/L Potassium 5.9 mEq/L Chloride 101 mEq/L Bicarbonate 22 mEq/L Blood urea nitrogen 110 mg/dl Glucose 1000 mg/dl Serum calcium 10.2 mg/dl Amylase 100 U/L Aspartate aminotransferase 15 U/L Alanine aminotransferase 17 U/L Ammonia 15 micro-moi/L (Normal is 9-33 micro-moi/L) PT 13 sec APTT 30 sec Arterial blood gases: PH 7.40 PaCO2 38 mm Hg PaO2 90 mm Hg Which of the following is the most appropriate initial infusion you should order for this patient?

Four of your patients who came to the office today all have signs and symptoms of hyperthyroidism. After the appropriate evaluation, you decided to treat them with radioactive iodine. Hyperthyroid patients with which of the following disorders are most likely to develop hypothyroidism following radioactive therapy?

A 60-year-old Caucasian male presents to the office with erectile dysfunction that progressed slowly over the last several months. He finds it difficult to obtain an erection, and has noted a decrease in nocturnal erections. His past medical history is significant for diabetes mellitus, type 2 and benign prostatic hypertrophy (BPH). His current medications are glyburide and doxazosin. Physical examination is insignificant. HbA1c level measured two weeks ago was 7.5%. He is asking about a prescription for sildenafil. Which of the following is the best statement concerning the treatment of erectile dysfunction in this patient?

A 58-year-old asymptomatic male is found to have elevated levels of serum alkaline phosphate. His serum calcium and phosphate levels are normal. He denies any bone pain or deformity. His liver function tests are normal. The urinary hydroxyproline levels are increased. Nuclear bone scan reveals an increased uptake in the right scapula. Plain radiography confirms Paget's disease. Which of the following is the most appropriate next step in the management of this patient?

A 56-year-old male presents in the emergency department with severe nausea, vomiting, polyuria, polydipsia, and constipation. His past medical history is significant for hypertension and type 2 diabetes mellitus. His home medications include metformin, atenolol, and hydrochlorothiazide. He has a 26-pack-year history of smoking. He drinks alcohol occasionally. He denies the use of recreational drugs. His father also has diabetes mellitus type 2. His blood pressure is 110/70 mmHg, pulse is 102/min, temperature is 36.7C (98F) and respirations are 16/min. His mucus membranes are dry. His lung examination reveals decreased breath sounds over the right base. The rest of the physical examination is unremarkable. The patient is subsequently admitted. Laboratory studies (obtained in the emergency department) are as follows: Serum calcium 14.8 mg/dl Albumin 4.0 g/dl PTH 9 pg/ml (normal 10-60 pg/ml) Serum creatinine 1.9 mg/dl BUN 54 mg/dl Blood glucose 180 mg/dl 25-hydroxyvitamin D 30 ng/ml (normal 20 to 60 ng/ml) 1,25-dihydroxyvitamin D 30 pg/ml (normal 15 to 65 pg/ml) What is the most likely cause of this patient's hypercalcemia?

A 23-year-old man presents to your office complaining of occasional headaches, muscle weakness and fatigue. He also describes periodic numbness of his extremities. The symptoms started 6 months ago and have gradually progressed. His past medical history is insignificant. He is not taking any medication. His blood pressure is 165/104 mm Hg and heart rate is 80/min. His physical examination is within normal limits. Which of the following laboratory findings is the most specific for the patient's condition?

A 63-year-old otherwise healthy male presents with a thyroid nodule. He denies any symptoms of anxiety, heat or cold intolerance, and recent changes in appetite or weight. He has hypertension, which is being treated with a beta-blocker. He does not have any other medical problems. He denies any family history of thyroid disease. His pulse is 79/min and blood pressure is 130/76 mmHg. Neck examination shows a hard, fixed, non-tender, 4 cm thyroid nodule in the right thyroid lobe. His serum TSH level is normal. Fine needle aspiration biopsy (FNAB) shows follicular cells. Follicular carcinoma is suspected. Which of the following is necessary to make a diagnosis of follicular thyroid cancer?

A 28-year-old avid mountain climber and his friend are vacationing in Andes, South America. During their mountain climbing expedition, the pair somehow manages to get lost. It has been over 16 hours since their food supply ran out. Their glycogen stores are becoming depleted, and their bodies are beginning to utilize the process of gluconeogenesis. Which of the following intermediates is alanine being converted into during this process?

A 38-year-old Caucasian female presents to the office complaining of lethargy, weight gain and fatigue. She denies headaches, pruritus or urine discoloration. She just gave birth 2 months ago via vaginal delivery; her baby is in good health and receives formula nutrition. Her delivery was complicated by vaginal bleeding that required blood transfusion, and postpartum endometritis that rapidly responded to antibiotics. She has not had any menstrual periods following delivery. Physical examination shows sparse pubic hair, dry skin and delayed tendon reflexes. Urinalysis shows no glucose or ketones. Which of the following is most likely to be responsible for this patient's condition?

A 58-year-old Caucasian male presents with polyuria and polydipsia for the past 4 months. He also reports easy bruising and difficulty in climbing stairs. He weighs 180 lbs (81.6kg) and is 5'7"(170cm) tall. His temperature is 37C (98.6F), pulse is 76/min, blood pressure is 155/100 mm Hg, and respirations are 15/min. Physical examination reveals significant proximal muscle weakness of all the extremities. Skin examination reveals significant pigmentation on the exposed areas. Lab studies show: Sodium 145 meq/L Potassium 2.9 meq/L Bicarbonate 30 meq/L Fa sting blood glucose 240 mg/dL Hemoglobin 13 g/dL WBC 14,000/micro-L Neutrophils 70% Lymphocytes 23% Monocytes 5% Basophils 1% Eosinophils 1% 24hr urinary free cortisol 1100 microgram Plasma ACTH 250 pg/mL (Normal 9-52 pg/mL). High dose dexamethasone suppression test did not decrease the 24 hr urinary cortisol excretion. Which of the following is consistent with this patient's findings?

A 56-year-old woman presents to the clinic with a 7-month history of headache and visual disturbance. Her past medical history is unremarkable. She is currently not taking any medications. She admits to smoking a pack of cigarettes daily for the last 15-years, and does not drink. On visual field examination, there is a small field defect noted in both eyes. MRI scan shows a pituitary tumor. Which of the following is the most common type of pituitary tumor?

A 65-year-old Hispanic male comes to the office for a routine medical check-up. He has a history of diabetes for the past twenty years, and hypertension for the past ten years. His daily medications include insulin and ramipril. He was diagnosed with nonproliferative diabetic retinopathy at his last ophthalmologic visit. Reports from his previous laboratory studies show microalbuminuria. A detailed neurological examination is performed to check for any neuropathy. Which of the following is the most common type of neuropathy found in diabetics?

A 46-year-old male comes to your office for a routine health examination. He has no current physical complaints and says he is compliant with his medications. His past medical history is significant for type 2 diabetes diagnosed two years ago that he has been able to control with diet, exercise and metformin. The patient also takes a daily aspirin. On physical examination, he has a temperature of 36.7C (98.F), a blood pressure of 140/86 mm Hg, a pulse of 80/min, and respirations of 14/min. His laboratory studies show: Total cholesterol 170 mg/dl High density lipoprotein (HDL) 50 mg/dl Low density lipoprotein (LDL) 65 mg/dl Triglycerides (TG) 150 mg/dl HbA1C 7.0 Serum chemistries are with in normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 60-year-old white male is hospitalized due to an acute myocardial infarction. His other medical problems include type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and degenerative joint disease. He admits to smoking 2 packs of cigarettes daily for the past 20 years, as well as drinking 2 bottles of beer daily for the past 15 years. His medications include aspirin, glyburide, metoprolol, enalapril, heparin, and albuterol and ipratropium inhalers. His blood pressure is 140/80 mm Hg, pulse is 80/min, respirations are 16/min, and temperature is 36.7C (98.0F). During his stay in the hospital, a number of blood tests were ordered. Which of the following lab abnormalities is an indication for thyroid function testing?

A 45-year-old unconscious male is brought to the emergency room. His airway is secured, oxygen is administered, and his vitals are as follows Temperature 364 C (97.8F); PR 102/min; BP 90/65 mm of Hg; RR 27/min. An IV line is secured and blood and urine samples are drawn. Lab results are as follows: Blood urea nitrogen 40 mg/dl Calcium 9.1 mg/dl ALT 50 U/L AST 60 U/L Ammonia 15 micro-mol/1 (Normal is 9-33 micro-mol/1) PT 13 sec APTT 30 sec Amylase 100 U/L Glucose 400 mg/dl Sodium 134 meq/L Potassium 5.2 meq/L Chloride 97 meq/L Bicarbonate 12 meq/L Arterial Blood Gases: PH 7.19 PaCO2 25 mm Hg PaO2 80 mm Hg Blood and urine are positive for ketones. A diagnosis of diabetic ketoacidosis (DKA) is made and IV infusion of normal saline and regular insulin are started. What will be a most reliable index for monitoring the response to treatment?

A 27 -year-old woman presents to the office due to a significant amount of hair on her cheeks, chin and upper lips. This symptom developed over the past two months. Her last menstrual period was 12 weeks ago, but she did not seek medical help because her home pregnancy test was negative. Her medical history is unremarkable. She denies taking any medications other than oral contraceptive pills. Physical examination reveals acne on the forehead and cheeks; there is terminal hair on the upper lip, cheeks, chin, upper chest and lower abdomen. Examination of the genitals shows clitoromegaly. The abdominal exam is normal; the uterus is normal in size. Ultrasound reveals a normal uterus and ovaries, but there is a left adrenal mass. Which of the following measurements is most specific for this patient's condition?

A 35-year-old white female presents with complaints of weight gain, lethargy and constipation for the last 2 months. She also complains of cold intolerance and oligomenorrhea. She is not taking any medication. She is a non-smoker, and does not drink alcohol. Her pulse is 67/min, and blood pressure is 130/90 mm Hg. She is afebrile. Her hands are dry and cold. There is a non-tender, diffuse rubbery enlargement of the thyroid gland without any discrete nodularity. She does not have exophthalmos, lid lag or lid retraction. Labs show decreased serum T4 levels, elevated serum TSH levels and positive anti-thyroperoxidase (TPO) antibodies. Which of the following complications may develop in this patient?

A 35-year-old white female comes to her primary care physician for the evaluation of palpitations, weight loss, increased appetite and diarrhea for the past 2 months. She denies smoking cigarettes or drinking alcohol. Her temperature is 37.1C (98F), blood pressure is 135/80 mm Hg, respirations are 14/min, and pulse is 90/min. Physical examination shows exophthalmos, lid lag, lid retraction, and a diffusely enlarged, non-tender thyroid gland. Lab studies show very low levels of serum TSH, and increased levels of serum free T4 and T3. The diagnosis of Graves' disease is established. Various treatment options are discussed with the patient, and she opts for long-term treatment with propylthiouracil. Which of the following conditions is this patient at risk for developing?

A 16-year-old female presents to the office with her mother and complains of changes in her physical appearance over the past year. She first noted the appearance of dark hair on the cheeks, upper lips, around the nipples and umbilicus. Her menstrual cycles have always been irregular since her menarche at age 14. Her medical history is otherwise unremarkable. She denies taking any medications. She has a boyfriend, but claims that she is still not sexually active. Her blood pressure is 115/65 mm Hg, pulse is 80/min, respirations are 16/min, and temperature is 37 C (98F). Pelvic examination could not be performed, and abdominal examination is normal. Ultrasound is normal. Results of the initial work-up are as follows: Serum Na+ 140mEq/L Serum K+ 4.0mEq/L Serum Cl- 98 mEq/L Bicarbonate 25 mEq/L 1 7-alpha-hydroxyprogesterone elevated According to these findings, which of the following hormone deficiencies does this patient most likely have?

A 21-year-old man with type 1 diabetes mellitus presents to the emergency department with complaints of abdominal pain, nausea and vomiting. His temperature is 36.0C (97.0F), pulse is 110/min, blood pressure is 102/60 mm Hg, and respirations are 26/min. Lungs are clear to auscultation. Abdomen is soft, non-tender and non-distended. Chemistry panel shows: Sodium 130 mEq/L Potassium 5.2 mEq/L Chloride 90 mEq/L Bicarbonate 10 mEq/L Blood glucose 450 mg/dl Which of the following is the most appropriate next step in management?

A 40-year-old female patient is brought to the office by her husband due to altered mental status and confusion of recent onset. According to her husband, she has been complaining of intense thirst, craving for ice water, and experiencing increased urination for the past few days. Her only medication is lithium for bipolar depression. Her temperature is 39.0C (102.5F), pulse is 102/min, blood pressure is 90/60 mm Hg, and respirations are 15/min. Physical examination reveals a disoriented patient with dry skin and mucous membranes. Blood chemistry panel reveals: Sodium 156 mEq/L Potassium 4.1 mEq/L Bicarbonate 26 mEq/L Blood glucose 1 02 mg/dl BUN 27 mg/dl Serum osmolality is 328mOsm/kg, and urine osmolality is 180mOsm/Kg. What is the most appropriate next step in the management of this patient?

A 60-year-old Caucasian male presents to your office complaining of decreased hearing on the right side. He also feels that something is wrong with his head because his hat size had increased over the last two years. His past medical history is significant for hypertension and peptic ulcer disease. His current medications are hydrochlorothiazide and enalapril. He also takes ibuprofen for occasional headaches, and ranitidine for infrequent episodes of heartburn. Lab tests showed increased alkaline phosphatase levels. Which of the following is the most likely mechanism underlying this patient's condition?

A 40-year-old asymptomatic male comes to the office for a routine physical examination. His serum chemistry panel shows: Sodium 140 mEq/L Potassium 4.0 mEq/L Bicarbonate 25 mEq/L Chloride 101 mEq/L Calcium 11.8 mg/dL Albumin 4.0 g/dL Phosphorus 2.2 mg/dL 24-hour urine collection reveals a calcium level of 200 mg, and creatinine level of 1.7 g. Serum PTH level is increased. Bone mineral density by dual energy X-ray absorptiometry (DEXA) shows normal bone mineral density. Neck examination reveals no masses. What is the most appropriate next step in the management of this patient?

A 38-year-old woman presents with several months of decreased libido and a 4.5-kg (10-lb) weight gain. She has not had her menstrual period for the past 3 months. Physical examination is unremarkable except that a small amount of white discharge is manually expressed from the nipples bilaterally. The serum prolactin level is 300 ng/mL. Which of the following is the most appropriate first-line treatment?

A 72-year-old woman presents to her physician complaining of fatigue, malaise, weight loss, and salt cravings. The patient has chronic obstructive pulmonary disease and is intermittently treated with corticosteroids but is not using home oxygen. Her oxygen saturation is 97% on room air with a blood pressure of 115/65 mm Hg, which is significantly lower than her baseline of 125/78 mm Hg. On auscultation she has good breath sounds bilaterally without wheeze, although the expiratory phase is slightly prolonged. Five weeks ago she received a corticosteroid treatment for an acute chronic obstructive pulmonary disease exacerbation, for which she was hospitalized and given 3 L of oxygen via nasal cannula. However, she admits that after discharge she was having continued difficulty breathing and did not follow the taper of the corticosteroids. The patient has smoked one pack of cigarettes per day for the past 51 years. Which of the following is the appropriate first step in the management of this patient?

An obese patient with a long-standing history of type 2 DM presents to his primary care physician. On examination he has decreased sensation in both lower extremities. Upon questioning of his compliance with his prescribed medications, he reports that he has stopped taking one medication because it gave him flatulence and abdominal pain. Which of the following did this man most likely stop taking?

A 37 -year-old white female presents with galactorrhea and amenorrhea for the past 7 months. She denies any headaches, visual problems, vaginal dryness or dyspareunia. She is married, has two children, and remarks that her family is "complete." She does not use tobacco, alcohol or drugs. Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min. Visual field testing is within normal limits. Pregnancy test is negative. Her serum prolactin level is 150ng/ml. Pituitary MRI shows a 6mm pituitary adenoma. Which of the following is the most appropriate next step in the management of this patient?

A 30-year-old Caucasian female comes to the physician's office because of polyuria and polydipsia of recent onset. She has no other medical problems. She does not use tobacco, alcohol or drugs. She has no known drug allergies. Her mother has diabetes. Her temperature is 36.7C (98F), pulse is 75/min, blood pressure is 110/70 mm Hg, and respirations are 15/min. The initial lab results are: Hb 12.7 g/dl WBC 5,000 /cmm Platelets 380,000/cmm Blood glucose 90 mg/dl Serum sodium 142 mEq/L Serum potassium 4.0 mEq/L Bicarbonate 26 mEq/L BUN 15 mg/dl Serum creatinine 0.9 mg/dl Serum uric acid 9 mg/dl Serum osmolality 295 mOsm/kg Urine osmolality 160 mOsm/kg After 12 hours of water deprivation, lab testing reveals: Serum sodium 151 mEq/L Serum potassium 4.2 mEq/L Bicarbonate 26 mEq/L Serum osmolality 300 mOsm/kg Urine osmolality 186 mOsm/kg One hour after the subcutaneous administration of arginine vasopressin, the urine osmolality is 400mosm/kg. Which of the following is the most appropriate treatment for this patient?

A 45-year-old woman with chronic alcohol abuse admitted 3 days ago for nausea and severe diarrhea now complains of perioral and finger tingling. She was admitted for hydration after 1 week of severe watery diarrhea. She has been receiving intravenous hydration and dextrose but has not been able to take oral nutrition secondary to continued nausea. Her blood pressure is 130/74 mm Hg, pulse is 68/min, and respiratory rate is 16/min. She is afebrile. Physical examination is significant for facial twitching on percussion of her facial nerve just anterior to the ear, as well as the induction of carpal spasm after the inflation of a blood pressure cuff on her arm. Which of the following is most likely to have caused these findings?

A 42-year-old woman with no significant past medical history presents for a routine health maintenance visit. On physical examination a solitary nodule is palpated in the thyroid. She denies pain, dysphagia, or hoarseness. She also denies fatigue, weight change, heat or cold intolerance, diarrhea, or constipation. There is no family history of thyroid cancer. Her serum thyroid-stimulating hormone level is normal. Which of the following is the most appropriate next step in evaluation?

A 60-year-old man presents to his primary care physician for routine medical care. He has no complaints, takes no medications, and has a family history of DM. Examination is unremarkable. A screening laboratory test reveals a fasting blood glucose level of 152 mg/dL. One week later the test is repeated and a value of 144 mg/dL is obtained. Which of the following is the most likely cause of these findings?

A 90-year-old male complains of hip and back pain. He has also developed headaches, hearing loss, and tinnitus. On physical examination the skull appears enlarged, with prominent superficial veins. There is marked kyphosis, and the bones of the leg appear deformed. Serum alkaline phosphatase is elevated. Calcium and phosphorus levels are normal. Skull x-ray shows sharply demarcated lucencies in the frontal, parietal, and occipital bones. X-rays of the hip show thickening of the pelvic brim. Which of the following is the most likely diagnosis?