Exam Master: Endocrinology

A 43-year-old Caucasian woman presents for evaluation of menstrual irregularities over the past 6 months, despite of history of prior regular menses. She had a bilateral tubal ligation (BTL) and reports multiple negative home pregnancy tests. The patient also notes weight gain and increased girth in her abdomen. She reports easy bruising without a history of trauma; she also notes the new development of "stretch marks" on her torso, and there is also weakness in her arms and legs. She denies any health changes, medications, or stressors in relation to these changes. She denies hot flashes, night sweats, and frank depression; however, she admits to some mood swings and poor libido. The patient is frustrated that her health fair labs (which include complete blood count, complete metabolic panel, lipid panel, and thyroid stimulating hormone) were all normal and do not explain her symptoms. Her past medical history reveals no chronic conditions; she does not take any medications, and she has no known drug allergies. Her only surgery was the BTL. She lives with her husband and 3 children. She works as a retail clerk and walks for exercise. She denies the use of tobacco, alcohol, and drugs. Her blood pressure is 154/92. Chart review demonstrates weight gain of 15 pounds over 6 months. She has had normal blood pressures in the past. On physical exam, you observe an overweight woman with an especially rounded, full face. She also has a fatty fullness to her neck region, and there is some central obesity; however, her arms show some muscle wasting. She has purple striae on her torso. Her skin also appears thinned, with multiple bruises. Hirsutism is observed on the patient's chin, abdomen, and breasts. The remainder of her exam was unremarkable. Testing confirms elevated ACTH and high cortisol levels in the evening and after dexamethasone suppression, as well as a pituitary macroadenoma as the cause. What prescription medication may be indicated after the surgical removal of her tumor? 1 Aldosterone 2 Insulin 3 Levothyroxine 4 Parathyroid hormone 5 Prolactin

3 Levothyroxine

A 50-year-old man presents for a follow-up exam. He has a 2-year history of diabetes. His previous physician had placed him on glipizide 5 mg/day. At his visit 3 months ago, you found that his recent ophthalmologic visit revealed no retinopathy, his renal function was stable, and his physical exam was negative except for morbid obesity. After the visit, he consulted a nutritionist and modified his diet based on her suggestions. At that time, his hemoglobin A1C was 6.8%; you elected to make no changes in his medical regimen. At this visit, you discover that his weight has gone up 5 lbs. and his hemoglobin A1C has gone up to 7.3%. He denies drinking any alcohol, taking any herb supplements, or following any fad diets. His only medications are the glipizide and 1 multivitamin. At this point, what should you tell the patient to do? 1 Add metformin to his glipizide 2 Start insulin therapy 3 Add a thiazolidinedione 4 Change his glipizide to metformin 5 Increase his level of exercise

4 Change his glipizide to metformin

A 44-year-old woman undergoes surgery for a follicular neoplasm of the thyroid gland. The tumor is successfully resected, and she is transferred to the post-operative ward. Her condition is noted to be stable. On post-operative day 2, she notices a tingling sensation around her lips that runs down her arms. She experiences a cramping sensation in the muscles of her hands and legs, with her fingers going into spasm. An intern on the floor notices the patient's distress and decides to investigate. Question What is the best initial diagnostic test? 1 Serum free T3 and T4 2 Serum TSH 3 Arterial blood gas analysis 4 Serum calcium levels 5 CT scan of the anterior neck

4 Serum calcium levels

A 42-year-old Hispanic man presents because his employee health fair lab results returned with several 'out of normal' range results. He is an established patient in your practice; you have seen him 4 times for illness or minor injury over the past 10 years. He reports that he is in generally good health and feels well; he does not see any other healthcare providers. A summary of his past medical history includes: Medications: occasional over-the-counter ibuprofen for joint pain Allergies: none Surgical history: open reduction of left ankle at the age of 22 years Medical history: mild osteoarthritis Social history: patient denies the use of tobacco or illicit drugs. He drinks 3 - 4 beers per week. He is married and has 5 kids; he works in industrial hygiene at a lab facility. He plays rugby on the weekends as a hobby. Family history: no chronic diseases are known to the patient. His vital signs at check-in were all in normal ranges. This patient's laboratory results from the health fair are shown in the chart. Complete blood count (CBC) WBC 6.1 3.6 - 9.0 K/μL RBC 4.78 4.18 - 5.22 M/ μL Hemoglobin 15.4 12.9 - 15.5 g/dL Hematocrit 45.2 34.6 - 50.1% MCV 94.6 80.0 - 100.0 fL MCH 32.2 27.0 - 34.0 pg MCHC 34.1 30.0 - 37.0 g/dL RDW 11.7 11.0 - 17.0% Platelets 462 140 - 440 K/μL MPV 9.9 6.5 - 12.0 fL WBC differential Normal Complete Metabolic Panel (CMP) Sodium 132 134 - 144 mmol/L Potassium 3.3 3.4 - 4.9 mmol/L Chloride 100 100 - 109 mmol/L HCO3 26 20 - 31 mmol/L Glucose 94 70 - 99 mg/dL Bun 20 7 - 18 mg/dL Creatinine 1.1 0.6 - 1.2 mg/dL Calcium 9.9 8.8 - 10.5 mg/dL Albumin 3.5 3.5 - 5.0 g/dL Total Protein 6.3 6.4 - 8.2 g/dL AST (SGOT) 21 15 - 37 U/L ALT (SGPT) 17 5 - 43 U/L Alk Phosphatase 55 50 - 136 U/L Total Bilirubin 0.8 0.1 - 1.2 mg/dL Anion Gap 6 6 - 16 mmol/L eGFR >60 >60 mL/min/1.73m2 Cholesterol 226 </=200 mg/dL Triglyceride 864 </=150 mg/dL HDL 42 40 - 59 mg/dL LDL Unable to calculate VLDL Unable to calculate TSH 1.960 0.500 - 4.700 uIU/mL Assuming you have counseled the patient on his condition and recommended lifestyle changes, what is the most appropriate prescription for him at this time? 1 Cholestyramine (Questran or Prevalite) 2 Clopidogrel (Plavix) 3 Ezetimibe (Zetia) 4 Lisinopril (Zestril or Prinivil) 5 Nicotinic acid (niacin)

5 Nicotinic acid (niacin)

A 33-year-old man presents for his biannual checkup. He was diagnosed with Type I diabetes at the age of 4 and has been on insulin since then. 2 years ago, he was switched to a continuous subcutaneous insulin infusion system. He exercises regularly, controls his diet, and has had his sugar well controlled for the past few months, checking regularly with home monitoring. His BP is 120/75, pulse 70/min, no JVD, and cardiovascular and respiratory exam are normal. In addition to eye and foot exams, the physician wants to assess the patient's renal function. Question What is the best initial screening test? 1 Serum creatinine 2 Blood urea level 3 Urine specific gravity 4 24-hour urine protein 5 Urine dipstick for protein

5 Urine dipstick for protein

A 40-year-old woman presents with swelling in her neck, which has gradually increased in size in the past year. On physical examination, her thyroid gland is symmetrically and diffusely enlarged and non-tender. Serum TSH is 12 mU/L (normal 0.4-4 mU/L). The patient was subjected to thyroidectomy. On microscopic examination, it shows extensive infiltration of the parenchyma by a mononuclear infiltrate containing small lymphocytes, plasma cells, and well-developed germinal centers. The thyroid follicles are small; in many areas, they are lined by Hurthle cells. Question What is the most likely diagnosis? 1 Hashimoto thyroiditis 2 Juvenile lymphocytic thyroiditis 3 Atrophic thyroiditis 4 Painless thyroiditis 5 Graves' disease

1 Hashimoto thyroiditis

A 32-year-old woman presents with constipation, weight gain, and dry skin. She has been experiencing the symptoms for a few months. Examination findings include dry rough skin, diffuse thyroid enlargement, bradycardia, and edema of hands and feet. A thyroid profile is performed and shows elevated thyroid stimulating hormone (TSH) and the presence of thyroid antibodies-antithyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies. The tissue biopsy microscopy is revealed in the image, with areas of interest indicated by the arrows. Question What is the most likely cause of these findings? 1 Hashimoto's thyroiditis 2 Riedel's Thyroiditis 3 Subacute painless thyroiditis 4 Suppurative thyroiditis 5 De Quervain's Thyroiditis

1 Hashimoto's thyroiditis

The most common type of thyroiditis in the US is associated with increased circulating levels of antithyroid peroxidase or antithyroglobulin antibodies. With what condition is it most likely to be associated? 1 Hashimoto's thyroiditis 2 Riedel's Thyroiditis 3 Subacute thyroiditis 4 Suppurative thyroiditis 5 De Quervain's Thyroiditis

1 Hashimoto's thyroiditis

A 25-year-old woman presents because of changes in her eyes, heat sensitivity, constant sweating, and nervousness. She has lost 15 pounds recently. Her doctor suspects that she has Graves' disease. She asks her doctor why her thyroid is enlarged. What is the correct term for the underlying phenomenon in her illness? 1 Hyperplasia 2 Hypertrophy 3 Metaplasia 4 Dysplasia 5 Anaplasia

1 Hyperplasia

A 38-year-old woman presents for treatment of a minor burn on her left hand. She is nervous, hyperexcitable, and experiencing palpitations. Her pulse is up to 110/min; her blood pressure is 120/80 mm Hg, and you notice a fine tremor of her hands. Upon further questioning, she tells you that she has been losing weight even though she's been eating a lot; she also sweats a lot, especially at night, and she has problems sleeping. She also notes frequent bowel movements, occasional diarrhea, and irregularities in her menstruation. What is the most likely diagnosis?

1 Hyperthyroidism

2 weeks after an upper respiratory infection, an adolescent presents with diarrhea, sweating, and increased heart rate. Physical examination reveals a tremor and a swollen, tender, and painful thyroid gland. Pulse rate is 110/min and blood pressure is 130/60 mm Hg. Refer to the attached laboratory studies. Serum T4: Increased Serum T3: Increased T3 Resin Uptake: Increased TSH: Decreased Radioactive iodine uptake: Very Low What is the appropriate treatment? 1 Symptomatic (NSAID, beta-blocking drug) 2 L-Thyroxin sodium 3 Thyroidectomy 4 Methimazole 5 Propylthiouracil

1 Symptomatic (NSAID, beta-blocking drug)

A 43-year-old woman was diagnosed with type II diabetes mellitus 6 months ago; she presents for follow up. The patient is presently asymptomatic. She currently receives oral hypoglycemics. The patient has no other significant medical history. Her glucose, acetone, lactate, and glycated hemoglobin are performed, and they are reported as follows: Serum Lactate 0.5 mEq/L Serum Acetone 0.4 mg/dl Fasting serum Glucose 130 mg/dl Glycated Hemoglobin 6% What is the best way to describe the patient's diabetic state? 1 The diabetic state is in good glycemic control 2 The diabetic state is not well controlled and the patient needs addition of another oral hypoglycemic agent 3 The diabetic state is not controlled and the patient's oral hypoglycemic dose needs to be increased 4 The patient's diabetic state is not in control and requires initiation of insulin therapy 5 The patient's diabetic state is well controlled and requires reduction in the dose of the oral hypoglycemic drug

1 The diabetic state is in good glycemic control

Your colleagues in the Psychiatry Clinic have asked you to see a woman who they wish to treat for depression. They want to know the status of her thyroid. The 75-year-old woman has a history consistent with depression. She mentions that she thinks her nursing home is cheating her by setting the thermostat too low at night. As a result of her statement, you close the examining room window against the hot July heat. You notice that she has hair loss at the lateral aspects of her eyebrows. She denies cosmetically altering them. Biochemically, she has low serum T3 and T4 and elevated TSH serum levels. Injection of TRH leads to even higher levels of TSH. At what level is the defect most likely to be located? 1 Thyroid 2 Pituitary 3 Hypothalamus 4 Thyroid and pituitary 5 Thyroid and hypothalamus

1 Thyroid

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and tremor in her hands. You note the presence of bulging eyes and suspect Graves' disease. What blood levels should be taken so that the disease can be confirmed? 1 Thyroid stimulating hormone 2 Thyroid peroxidase 3 Protein-bound iodine 4 Thyroglobulin 5 Thyrotropin-releasing hormone

1 Thyroid stimulating hormone

A 35-year-old woman presents with a 2-month history of palpitation and nervousness. She mentions that she always feels hot, even if the weather is cold. Her menses have been irregular lately. She has had no fevers recently. She was also told that her eyes are "weird looking". On examination, her blood pressure is 150/70 mm Hg, and her pulse rate is 89 beats per minute. Her eyes show exophthalmos, and she also has lid lag on looking down. Thyrotoxicosis is suspected. Thyroid scan shows activated thyroid with increased uptake. Question What is the nature of this patient's illness? 1 Autoimmune 2 Hypersensitivity 3 Neoplastic 4 Inflammatory 5 Malingering

1 Autoimmune The probable diagnosis in this patient is Graves' disease, which is autoimmune in etiology.

A 45-year-old man presents with multiple symptoms, including a 2-year history of chronic fatigue, headaches, and joint pain. He was finally prompted to seek care when he noticed an increase in both his hat and shoe size. His past medical history is unremarkable, with no known medical conditions; there is no history of surgery, and he does not take any medications. He lives with his girlfriend, and he works as a building contractor. On physical exam, his facial features appear "coarse"; he has a wide nose, and macroglossia is noted. The remainder of his physical exam is normal, and no observable abnormalities are noted on the patient's head or feet. Several tests are performed and significant findings include: Growth hormone Elevated Oral glucose tolerance test (OGTT) Elevated glucose levels Insulin-like growth factor-1 (IGF-1) Elevated Question After treatment of this patient's condition is initially completed, for what complication of this condition should he be monitored? 1 Cardiovascular disease 2 Hypogammaglobulinemia 3 Multiple myeloma 4 Osteoporosis 5 Parkinson disease

1 Cardiovascular disease

A 6-year-old boy presents due to lethargy, polyuria, nocturnal enuresis, and polydipsia. His mother tells you that he complains of being tired and thirsty all of the time. You note that he has lost 5 pounds since his last visit 6 months ago. What is the most likely diagnosis? 1 Diabetes mellitus type I 2 Diabetes mellitus type II 3 Leukemia 4 Lymphoma 5 Diabetes insipidus

1 Diabetes mellitus type I

A 35-year-old man with a 10-year history of type I diabetes presents with early fullness, abdominal pain, stomach spasms, heartburn, nausea, vomiting, bloating, and lack of appetite. Symptoms are getting progressively worse despite the patient's recommended lifestyle and dietary changes. Subsequent isotopic gastric emptying study confirms gastroparesis. Question What initial treatment should be suggested to this patient? 1 Erythromycin 2 Botulinum toxin 3 Misoprostol 4 Amoxicillin 5 A jejunostomy tube

1 Erythromycin

A 29-year-old pregnant woman presents for a prenatal check up. She is 6 months pregnant. She comments that she is constantly tired and is worried about her thyroid function because she has a friend who just had thyroid surgery. On physical examination, her pregnancy is progressing normally. Her thyroid is nonpalpable. No bruit over her thyroid is heard. Her skin is unremarkable. The doctor orders a series of blood tests. When the results come back, her doctor tells her that her abnormal lab results are probably due to a change in the level of thyroxine-binding globulin (TBG). Her lab results are on the chart. TEST RESULTS REFERENCE RANGE Serum total T4 15 µg/dL 5 - 11 µg/dL Free T4 2.5 ng/dL 1.5 - 3.5 ng/dL Question What condition does her blood test suggest? 1 Euthyroidism 2 Thyrotoxicosis 3 Hyperthyroidism 4 Hypothyroidism 5 Myxedema

1 Euthyroidism

A 27-year-old woman presents with a 2-month history of worsening irritability, fatigue, and weight loss. Her past medical history includes myasthenia gravis, but she is otherwise healthy. Question During her history taking, what positive review of systems symptoms would put hyperthyroidism on your differential list? 1 Excessive sweating, heat intolerance, heart palpitations 2 Hair loss, decreased energy, dry skin 3 Cramping, numbness around mouth, tingling in distal extremities 4 Bone pain, flank pain, anxiety 5 Dizziness, salt craving, chronic diarrhea

1 Excessive sweating, heat intolerance, heart palpitations A patient with hyperthyroidism could experience excessive sweating, heat intolerance, heart palpitations, and a myriad of other possible symptoms.

A 38-year-old woman presents for a consult regarding her thyroid disease. She was recently diagnosed with Graves' disease, and she has not started any treatment yet. Question What other finding might be observed that is present in about 5-10% of Graves' disease patients? 1 Exophthalmos 2 Conjunctivitis 3 Chemosis 4 Periorbital edema 5 Corneal abrasion

1 Exophthalmos

A 35-year-old woman presents with a 2-month history of palpitations and nervousness. She mentions that she always feels hot, even if the weather is cold. Her menses have been irregular lately. She has had no fevers recently. She was also told that her eyes are 'weird looking'. On examination, her blood pressure is 150/70 mm Hg and her pulse is 89 beats per minute. Her eyes show exophthalmos, and she also has lid lag on looking down. Thyrotoxicosis is suspected. The imaging shows activated thyroid with increased uptake. Question What is the most likely diagnosis? 1 Graves' disease 2 Toxic multinodular goiter 3 Hashimoto thyroiditis 4 Factitious hyperthyroidism 5 Toxic adenoma

1 Graves' disease

A 55-year-old man with no significant past medical history presents for a routine evaluation and fasting bloodwork. He does not note any symptoms at this time. His physical examination reveals an obese body mass index with a waist circmference of 120 cm and a blood pressure of 140/90 mm Hg, but he is otherwise unremarkable. His fasting bloodwork is drawn. Question What laboratory finding would qualify a diagnosis of metabolic syndrome in this patient? 1 HDL value of 35 mg/dL 2 Total cholesterol of 230 mg/dL 3 Triglyceride value of 125 mg/dL 4 LDL measurement of 110 mg/dL 5 Fasting plasma glucose of 95 mg/dL

1 HDL value of 35 mg/dL

A 34-year-old woman requests a prescription for Synthroid (levothyroxine) 125 mcg, which she takes 1 X day. The patient has no medical records, but you are able to ascertain she underwent previous transsphenoidal surgery for an enlarged pituitary gland. She was subsequently placed on thyroid hormone replacement medication and advised she must remain on this as a life-long medication routine. She admits to some fatigue and difficulty concentrating; otherwise, she is in her usual state of health. Further review of symptoms is unremarkable. Physical exam reveals coarse hair, patchy areas of dry skin, no periorbital edema or lid lag, no thyroid enlargement, and ankle reflexes +1/4. The remainder of the physical examination is within normal limits. Subsequent laboratory studies are as follows: Result Reference range TSH 0.25 0.40 - 4.5 mU/L Free T4 0.6 0.8 - 1.8 ng/dL Question What is the best therapeutic intervention? 1 Increase the dose of Synthroid (levothyroxine) 2 Decrease the dose of Synthroid (levothyroxine) 3 Continue the current dose of Synthroid (levothyroxine) 4 Discontinue Synthroid and initiate treatment with Tapazole (methimazole) 5 Obtain a thyroid Iodine131 uptake and scan

1 Increase the dose of Synthroid (levothyroxine)

A 46-year-old woman presents for a follow-up evaluation for her total thyroidectomy; it was performed 1 year ago for Stage II differentiated mixed papillary and follicular carcinoma. Laboratory tests were performed. What change in levels may suggest the recurrence of thyroid malignancy in this patient? 1 Increasing serum thyroglobulin levels 2 Decreasing serum thyroglobulin levels 3 Increasing T4 levels 4 Increasing TSH levels 5 Decreasing TSH levels

1 Increasing serum thyroglobulin levels

A 40-year-old woman presents with a 6-month history of a painless swelling on her neck. On examination, you find a nontender anterior neck swelling that rises with deglutition. Laboratory evaluation reveals normal thyroid function tests. Question What is the most likely diagnosis? 1 Iodine deficiency 2 Zinc deficiency 3 Copper deficiency 4 Folic acid deficiency 5 Cobalamin deficiency

1 Iodine deficiency

You are treating a 55-year-old man for the bilateral non-healing heel ulcers. He is a diabetic with poor glycemic control. He never accepted insulin therapy, and he is non-compliant to prescribed medications. Question What is likely to be the main reason for the delayed wound healing in this patient? 1 Leukocyte motility disorder 2 Hypokaliemia 3 Hypoglycemia 4 Metabolic syndrome 5 Hypercalcemia

1 Leukocyte motility disorder

A 45-year-old man presents with episodic attacks of headache, recurring bouts of palpitations, anxiety, and sweating. He also gives history of a severe attack 1 week prior; it occurred while he was having wine and cheese with his wife. On further questioning, he comments that he gets light headed when he stands up too rapidly. He comments that his mother had similar problems. On physical examination, his blood pressure is 165/90mmHg and his heart rate is 80/min. A 24-hour collection of his urine tests positive for vanillylmandelic acid. Imaging studies showed bilateral adrenal medullary hyperplasia. Further work-up showed hypercalcemia, hypophosphatemia, and increased parathyroid hormone levels. The positive family history and investigative findings are suggestive of multiple endocrine neoplasia (MEN) in this patient. Question MEN type II is characterized by pheochromocytoma (PCC), hyperparathyroidism and which of the following conditions? 1 Medullary carcinoma of the thyroid 2 Pituitary adenoma 3 Pancreatic islet cell carcinoma 4 Follicular carcinoma of the thyroid 5 Papillary carcinoma of the thyroid

1 Medullary carcinoma of the thyroid

A 21-year-old woman presents with urinary frequency; her BMI is 41. A urinalysis is positive for glucose. Her random blood sugar is 257 and hemoglobin A1C is 8.5%. She is diagnosed with type II diabetes, diet and exercise are recommended. What is the drug of choice for managing her diabetes? 1 Metformin (Glucophage) 2 Glipizide (Glucotrol) 3 Pioglitazone (Actos) 4 Insulin 5 Acarbose (Precose

1 Metformin (Glucophage)

A 42-year-old woman works full-time as a data entry clerk and often puts in many hours of overtime. She is experiencing numbness and tingling in her right thumb, index finger, middle finger, and half of her ring finger. The numbness and tingling initially comes and goes; however, after a few months, it is constantly present. Question What could be considered a predisposing condition for the most likely diagnosis? 1 Myxedema 2 Hyperthyroidism 3 Hyperparathyroidism 4 Hypoglycemia 5 Cushing syndrome

1 Myxedema

A 28-year-old woman presents because she is concerned about her 2, 4 and 6-year-old children. She doesn't have any symptoms, and there is nothing abnormal in her medical records. However, her father was recently diagnosed with medullary thyroid cancer due to the presence of MEN 2 A, and she is asking if the condition hereditary; if so, she wants to know what can be done in order to prevent her children from developing the malignancy. Question You explain the autosomal dominant trait of the disease; what advice should you provide? 1 RET mutation test in the patient 2 RET mutation test in children 3 Plasma calcitonin levels in children 4 Prophylactic total thyroidectomy 5 Carcinoembryonic antigen test in children

1 RET mutation test in the patient

A 19-year-old woman presents with weight loss, tiredness, and a decreased appetite. She mentions some nausea, and she vomited "once", but she denies diarrhea, illicit alcohol, and drug use, palpitations, tremor, and skin changes. Her urine dips positive for glucose and ketones. What would you likely see on physical exam? 1 Rapid deep breathing 2 Respiratory rate is unchanged 3 Moist mucous membranes 4 Heart rate is decreased 5 Respiratory rate is decreased

1 Rapid deep breathing The patient described here likely has diabetic ketoacidosis

As part of a routine checkup, a 40-year-old man is evaluated by his family practitioner. He smokes 1/2 a pack of cigarettes a day, and he has an occasional drink of wine. For the past 5 years, he has been on SSRIs for mild depression. On general physical examination, his BP is 110/70, and his BMI is 25. The physician notes slight enlargement of his thyroid gland with a solitary left upper lobe nodule. Careful examination reveals cervical lymphadenopathy. An FNAC of the nodule shows the picture below, with large amounts of amyloid stroma as well as disorganized spindle-shaped cells with large vesicular nuclei. His father developed "cancer of his throat"; it was diagnosed late, and he passed away a few months later. His elder brother is currently on medical management for an 'elevated calcium level'. Earlier he had had a surgery in his abdomen, which resolved his long-standing severe hypertension. He has no family history of cancer other than his father. Question What laboratory test would have helped identify the tumor at an early stage? 1 Serum calcitonin levels 2 BRCA mutation analysis 3 Werner's syndrome genetic testing 4 RET protooncogene testing 5 Radio iodine uptake scanning

1 Serum calcitonin levels

A 33-year-old man presents with his wife. He has been on a subcutaneous insulin infusion pump for the past 7 years for Type I diabetes. Prior to that, he was on an intensive insulin regimen for 13 years. As part of his examination, he has a fundoscopy done, which demonstrates the following picture. Question What intervention would have most likely prevented this patient's condition? 1 Yearly blood sugar levels 2 Aggressive blood sugar control 3 Adding metformin 4 Monthly administration of bevacizumab (Avastin) 5 Laser trabeculoplasty

2 Aggressive blood sugar control

A 28-year-old woman presents for a routine follow up. She is a type I diabetic and is on a multiple daily insulin injections regimen. At her last visit, she mentioned having difficulties with her morning glucose levels. She has been tracking her glucose levels daily. Her pre-breakfast glucose averages 285 mg/dL. At dinnertime, it averages 95 mg/dL, and it averages 68 mg/dL at 3 AM. Question What is the best change to make in her treatment regimen? 1 Increase the evening dose of long-acting insulin 2 Decrease the evening dose of long-acting insulin 3 Decrease the evening dose of short-acting insulin 4 Increase the evening dose of short-acting insulin 5 Increased activity before bedtime

2 Decrease the evening dose of long-acting insulin

A 70-year-old woman presents to the ED with nausea, anorexia, vomiting, fever, chills, and flank pain. Symptoms appeared abruptly after a 2-day history of mild dysuria. Her family reports that about 2 months ago, she started having urinary urgency and frequency and noted excessive urinary production of around 3-4 liters daily. She has a history of hypertension, poorly regulated type II diabetes, and mild cognitive impairment. Her long-term medications are aspirin and metformin, and 2 months ago, her family practitioner included furosemide, statin, and proposed insulin, but she was not willing to take any parenteral medication. Her fear of needles was the reason she gave for not agreeing to get recommended immunizations. On admission, she appears lethargic; her blood pressure is 80/40; pulse rate is 120; respiratory is 18; and temperature is 103.4. Question What is the primary risk factor responsible for her current condition? 1 Diabetes insipidus 2 Diabetes mellitus 3 Diuretic therapy 4 Cognitive impairment 5 Missed immunization

2 Diabetes mellitus

A 32-year-old woman presents for a follow up visit. She was diagnosed with hyperthyroidism 2 weeks earlier, after presenting with tremors, heat intolerance, weight loss, and diarrhea. You prescribed propranolol for her, pending the results of her test during her last visit. She feels slightly better now. She denies any family history of thyroid disorder and has no drug allergies. She has a supportive husband. She does not smoke, drink alcohol, or use illicit drugs. Her physical examination is normal. She has been reading about management of hyperthyroidism, and she prefers the 131I treatment. Question What is the most appropriate response to her request? 1 It cannot be used for females of childbearing age 2 Do a pregnancy test prior to starting therapy 3 Tell her surgery is the best approach 4 131I has been associated with a high recurrence rate 5 131I has been linked to cancer of the thyroid

2 Do a pregnancy test prior to starting therapy

A 46-year-old man presents for a routine check up. He drinks alcohol occasionally and quit smoking 20 years ago. His BP is 124/76 mmHg. He works as a salesman, but he wants to change to a desk job because he finds the commuting too stressful. His new employer requests that he have a full health check up prior to starting. He is concerned because his maternal grandmother and his father had diabetes. Question What is the best screening test to use? 1 HbA1c 2 Fasting Plasma Glucose 3 Post Prandial Plasma Glucose 4 75 gram Glucose Tolerance Test 5 100 gram Glucose Tolerance Test

2 Fasting Plasma Glucose

A 56-year-old man presents with signs and symptoms of hyperthyroidism in the presence of a palpable goiter. Laboratory studies are borderline suggestive, but they do not confirm thyrotoxicosis. Further testing includes a Radioactive I 131 Uptake (RAIU) and scan of the thyroid, which reveals a high uptake in a diffuse, uniform pattern throughout the gland. Question What is the most likely diagnosis? 1 Thyroiditis 2 Graves' disease 3 Toxic multinodular goiter (TMNG) 4 Toxic Thyroid Adenoma 5 Thyroid cancer

2 Graves' disease

A 40-year-old Caucasian woman, with a past medical history of Hashimoto's thyroiditis, type I diabetes mellitus, and pernicious anemia, presents with a 2-year history of insidious and intermittent fatigue, anorexia, involuntary weight loss, nausea, abdominal pain, vomiting, and dizziness associated with positional changes. Her physical exam is noteworthy for postural hypotension, with a maximum systolic blood pressure of 104 in the supine position. A fingerstick determination reveals a blood glucose of 100 mg/dL, and she has a normal urinalysis. She has a low-grade fever and a generalized pigment change to her skin, as noted in the attached image. The comprehensive metabolic panel demonstrates hyponatremia, hyperkalemia, a mild non-anion gap metabolic acidosis, and elevated BUN and creatinine levels. Question What is the most appropriate treatment for this patient? 1 Bromocriptine 2 Hydrocortisone 3 Insulin aspart 4 Metyrapone 5 Octreotide

2 Hydrocortisone

A 72-year-old woman presents with a 2-week history of fever, cough, and excessive diuresis. The woman has diabetes mellitus which is being treated with glimepiride (Amaryl). Her fluid and food intake have been poor during this time, as well. On physical examination, blood pressure is 98/58 mm Hg, pulse is 112/min, temperature is 100.6° F; and respirations are shallow and regular at 20/minute. On physical assessment, the patient is stuporous; skin and mucous membranes are dry, heart has a regular rate and rhythm without murmurs, and auscultation reveals rales in the left lung base. Based on this information, what is most likely causing the patient's condition? 1 Diabetic ketoacidosis 2 Hyperglycemic hyperosmolar state 3 Hypoglycemic coma 4 Lactic acidosis 5 Chronic renal failure

2 Hyperglycemic hyperosmolar state

A 19-year-old man has known type I diabetes on insulin; he is brought to the ER by his family with a history of clouding of consciousness, vomiting, shortness of breath, and weakness. Symptoms have been present since the morning. He also has a 2-day history of cough with productive sputum and fever. He is known to be non-compliant with insulin and diet and has had multiple ER visits. At home, his mother checked his blood sugar on his glucometer, which reported a "high level", signifying more than 500 mg/dl. On examination he is found to have a temperature of 101.5° F, pulse 110/min, BP 100/58 mm Hg, and respirations of 24/ minute. Skin and mucosa are very dry. Auscultation reveals crackles at the base of the right lung, tachycardia, and normal bowel sounds. He is drowsy but arousable and oriented. Labs are ordered, and supportive measures are started with fluids and insulin. Question The labs for the above patient show a blood sugar of 950 mg/dl, sodium 129 meq/L, chloride 91 meq/L, potassium 3.2 meq/L, BUN 35 mg/dL, creatinine 1.5 mg/dL, bicarbonate of 18 meq/L, anion gap 20, WBC 13,000/uL, serum ketones positive, and serum osmolality 300 mosm/kg. CXR shows right lower lobe consolidation and EKG shows tachycardia only. The best combination for the correct management of this patient includes fluids and what else? 1 SC insulin every 4 hours, potassium, bicarbonate, and antibiotics 2 Insulin drip, potassium, and antibiotics 3 Bolus insulin IV then SC every 4 hours, potassium, and antibiotics 4 IV insulin every 4 hours, potassium, and antibiotics 5 SC insulin every 2 hours, potassium, and antibiotics

2 Insulin drip, potassium, and antibiotics

A 36-year-old man with a past medical history of diabetes mellitus presents with weight gain and skin changes. His review of systems is positive for a diminished libido, impotence, depression, cognitive dysfunction, and emotional lability. Lately, his fasting glucose levels have been above normal. His physical exam notes increased adipose tissue in the face, upper back, and above the clavicles. His skin reveals ecchymoses, telangiectasias, and purpura along his back and lower extremities; there is also facial acne and cutaneous atrophy. His abdominal exam reveals the following findings. Question What is the most appropriate pharmacotherapeutic treatment for this patient? 1 Ketoconazole 2 Metyrapone 3 Mupirocin 4 Prednisone 5 Tacrolimus

2 Metyrapone

A 22-year-old woman presents with a 2-month history of weight loss; it is occurring despite the woman having a good appetite. She also reports of having frequent bouts of diarrhea. On detailed questioning, she reveals a feeling of heat intolerance and menstrual irregularity. The right lobe of the thyroid is palpably enlarged, and further investigations confirm the diagnosis of hyperthyroidism. What symptom is characteristic of hyperthyroidism? 1 Fatigue and lethargy 2 Palpitations and tremors 3 Slowed speech and movement 4 Thickening and dryness of skin 5 Impaired memory and sleepiness

2 Palpitations and tremors

A 43-year-old woman is found to have a palpable thyroid nodule. It is 1.5 cm in size, and it is located in the right lobe without regional lymphadenopathy. Upon questioning, the patient denies noticing this or any increase in the size of her thyroid. She denies hoarseness, a personal or family history of thyroid disease, and thyroid cancer. What is the most common form of thyroid cancer for which she is at risk? 1 Follicular 2 Papillary 3 Medullary 4 Hürthle cell 5 Anaplastic

2 Papillary

A 50-year-old woman has type 2 diabetes mellitus; she has been taking 500 mg of metformin daily for approximately 1 year. She has a hemoglobin A1c of 6.5%. She states that she carefully watches her diet, walks 1 mile almost every day, and monitors her blood sugar levels in the evening and before eating breakfast. Her blood sugar levels are often higher in the morning than they were the previous evening even though she does not eat anything. To what process can this be attributed? 1 Release to the bloodstream of glucose from glycogen in muscle 2 Release to the bloodstream of glucose from glycogen in the liver 3 Release to the bloodstream of glucose (from gluconeogenesis) from amino acids occurring in the liver 4 Continuous absorption of glucose into the bloodstream formed by the digestive system 5 Release to the bloodstream of glucose (from gluconeogenesis) from lactate occurring in the muscle

2 Release to the bloodstream of glucose from glycogen in the liver

A 43-year-old woman has an upper respiratory viral infection, with runny nose, fever, sneezing, and congestion. 2 days later, she notices pain in the front of her neck with swelling in that area. She notices more fatigue, palpitations, sweating, and anxiety; as a result, she has been unable to go to work. She has a temperature of 100.2 F, pulse 106/min, BP 110/70 mm of Hg, and respirations 16/minute. She looks nervous and tired. Neck exam reveals a tender vague mass anteriorly. Oropharynx is erythematous without exudates. No other masses are appreciated in the neck bilaterally. Lungs are clear and the abdomen normal. She is alert and oriented, and other than a fine tremor in her hands, no neurological deficit can be elicited. Lab work is ordered. What is the next best step in the work up of this patient? 1 Rapid streptococcal test and if negative, throat culture 2 TSH, T4, ESR 3 Serum thyroglobulin and thyroid ultrasound 4 Heterophile antigen test 5 Complete blood count with peripheral smear

2 TSH, T4, ESR This patient has a viral infection followed by infection of the thyroid gland, causing subacute thyroiditis, which is also known as de Quervain's syndrome.

A 45-year-old overweight man presents for a routine physical. He relates that he is always thirsty and urinates frequently at night. You order several blood tests, including a test for hemoglobin A1C. The levels of hemoglobin A1C level are 8.0, and you conclude that he has type II diabetes mellitus. You prescribe Glyburide, a sulfonylurea drug. After 3 months, his hemoglobin A1C level is 7.5. You add the drug Metformin, which drops the hemoglobin A1C to 6.8. What is the primary cause of the reduction in the patient's hemoglobin A1C level? 1 Reduction of fatty acid oxidation by metformin 2 The ability of metformin to decrease the production of glucose by the liver 3 Increased processing of proinsulin to insulin 4 Increased incorporation of GLUT4 into adipose tissue plasma membranes 5 Reduced clearance of glyburide from patient's serum

2 The ability of metformin to decrease the production of glucose by the liver

A 54-year-old woman presents to her primary care physician due to persistent fatigue. She notes feeling more thirsty than usual, and she has been getting up several times throughout the night to urinate. Her physician obtains the following labs: Fasting blood glucose 170 mg/dL 2 hour oral glucose tolerance test 230 mg/dL Hemoglobin A1C 9% Question What is the most likely diagnosis in this patient?

2 Type II diabetes mellitus

A 52-year-old man presents for his annual diabetic evaluation. He was diagnosed with Type II diabetes 10 years ago. He is on a strict diet and exercise regimen, takes metformin 3 times a day, and takes 75 mg of aspirin daily for his heart. His blood pressure is 135/80 mmHg. His lab values at evaluation are as follows: HbA1c - 6.9% Creatinine - 1.1mg% Blood Urea - 23 mg % AST - 40 IU/dL ALT - 42 IU/dL Urine Microscopy - Pus cells 1 - 2 per high power field, no red blood cells, protein - 1+ Ophthalmoscopy - Mild nonproliferative retinopathy Question What is the most appropriate next step? 1 Add a sulfonylurea to control blood sugar more aggressively 2 Advise him against consuming animal protein 3 Add a low dose ACE inhibitor 4 Schedule a renal sonogram to evaluate structural integrity of kidney 5 Refer to an ophthalmologist for laser photocoagulation of retinopathy

3 Add a low dose ACE inhibitor Addition of ACE inhibitor therapy has been proven in many trials to delay the onset of end stage renal disease in patients with diabetes.

A 60-year-old man is 3 years post-coronary artery bypass grafting. His last lipid profile showed: Lipid Result Triglycerides 165 mg/dL HDL 34 mg/dL LDL 135 mg/dL He is normotensive and almost chest-pain-free on isosorbide mononitrate and metoprolol. Given his lipid profile, how can this patient most appropriately be managed? 1 Fenofibrate, 134 mg daily 2 Simvastatin, 20 mg daily 3 Atorvastatin, 80 mg daily 4 Pravastatin, 20 mg daily 5 Lovastatin, 10 mg daily

3 Atorvastatin, 80 mg daily

A 12-year-old girl becomes comatose and is rushed to the hospital by her parents. 2 days before the admission, she went to school feeling ill. She vomited that evening. Her vomiting persisted with only an 8-hour pause during sleep. She is breathing deeply and rapidly; her breath has a fruity odor. Her parents mention that her appetite has increased. She has also been drinking lots of fluids; subsequently, she has been urinating more than normal. Urinalysis reveals 3+ glucose levels and 2+ ketone bodies. Question Based on the above information, what is the etiological cause of this patient's symptoms? 1 Insulin resistance 2 Increase in counterregulatory hormones 3 Autoimmune destruction of B-cells of pancreas 4 Post Epstein-Barr virus infection 5 Autoimmune destruction of pancreatic acini cells

3 Autoimmune destruction of B-cells of pancreas The etiology of Diabetes Mellitus Type I is autoimmune destruction of pancreatic B-cells

A 16-year-old girl presents with excessive fatigue and constipation that has developed over the past 3 months. Her eyes have become puffy and her weight has increased approximately 4 lb. Her skin is dry despite daily moisturizer application, and there is considerable hair loss. Her mother is under treatment for rheumatoid arthritis, and her father has hypertension. On physical examination, her thyroid is diffusely enlarged (twice the normal size) with a rubbery consistency. There is a slight peripheral edema and pallor of skin. Thyroid function tests show free T4 levels of 0.2 ng/dL and a TSH level of 96 mlU/L. What is the most likely underlying cause of her disease? 1 Thyroid hormone resistance 2 TSH-producing pituitary tumor 3 Autoimmunity 4 Iodine deficiency 5 Impaired thyroid response to TSH

3 Autoimmunity

A 58-year-old man with a past medical history of diabetes mellitus type II and hypothyroidism presents for a follow up of blood work results that were performed 1 week prior. His low density lipoprotein level was found to be 150 mg/dL; total cholesterol level was 230 mg/dL; high-density lipoprotein was 36 mg/dL; and triglyceride levels were 260 mg/dL. He denies any complaints at this time and is compliant to the only medications he takes, which are Levothyroxine 137 mcg/day and Metformin 500mg twice a day. His labwork demonstrated a euthyroid state and a hemoglobin A1c of 6.1%. Question What is an appropriate step in the management of this patient? 1 Recommend a 300 mg/day cholesterol diet 2 Prescribe aspirin 325 mg every day 3 Begin rosuvastatin 10 mg every day 4 Restrict fiber and fruit intake 5 Prescribe cholestyramine resin daily

3 Begin rosuvastatin 10 mg every day

A 34-year-old African-American woman presents with recurrent vaginal yeast infections. Over the past 2 years, she has had repeated episodes of similar infections that have been only partially responsive to over-the-counter treatments. She has not seen a physician in the 5 years since her last pregnancy, and she denies a history of any major medical illness. She has been moderately obese for most of her adult life; her maximal weight was 240 lb. at a height of 5'1"; however, she has recently had a 15 lb. unintentional loss in weight. She also reports nocturia for the past several months. Physical examination is remarkable for a blood pressure of 155/95 mm Hg, obesity, and findings consistent with vaginal candidiasis. Question What is the most useful test for underlying disease diagnosing in this patient? 1 A 50 g oral glucose tolerance test 2 A 100 g oral glucose tolerance test 3 Blood glucose after an overnight fast (FBG) 4 Point-of-care (POC) Hemoglobin A1c (HbA1c) level 5 Immediate measurement of blood glucose concentration

3 Blood glucose after an overnight fast (FBG)

Classic symptoms of polyuria, polydipsia, and weight loss in a pediatric patient is likely due to autoimmune damage of the insulin-producing β-cells of the pancreatic islets. Symptoms usually appear gradually, and they occur when at least 80% of the islets have been damaged. Question What is the most likely diagnosis of this pathological process? 1 Acute pancreatitis 2 Hypothyroidism 3 Diabetes type I 4 Diabetes type II 5 Cushing's syndrome

3 Diabetes type I

A 5-year-old girl presents with a 2-month history of a gradually increasing swelling in the neck. The child is otherwise asymptomatic. There is a similar complaint in most neighboring children. Cauliflower is the main crop in the region. She has no other developmental problems. On physical exam, her thyroid gland is non-tender, soft, and symmetrically enlarged without any palpable nodules or signs of compression. The thyroid function test showed slightly low thyroxine (T4) and normal TSH and triiodothyronine (T3) levels. Her urinary iodine level was also low. Question What is the most likely diagnosis? 1 Toxic nodular goiter 2 Graves' disease 3 Diffuse non-toxic goiter 4 De Quervain thyroiditis 5 Multinodular goiter

3 Diffuse non-toxic goiter

A 24-year-old woman has recently been diagnosed with insulin-dependent diabetes. The disease is being managed on a split dose of 60/40 insulin suspension, which she injects herself at 8:00 a.m. and 5:00 p.m. She was told to call in if she experiences any strange symptoms, which she does this afternoon. At 2:45 p.m., she is not feeling well and notices that her skin is cool and damp. Her hands are shaking and she is very anxious. Question What do you tell her to do right away, before having somebody take her to your office? 1 Inject 4 IU of her insulin 2 Drink a can of diet soda 3 Drink 4 ounces of fruit juice 4 Eat a large candy bar 5 Eat a cube of sugar

3 Drink 4 ounces of fruit juice

A 58-year-old man with no significant past medical history presents for an initial medical evaluation and bloodwork. He mentions no symptoms at this time. His physical examination reveals an obese body mass index. His blood pressure is 142/90 mm Hg, and the patient is remarkable for the findings shown in the attached image. Question What is a correct conclusion regarding the laboratory evaluation of this patient? 1 C-reactive protein and homocysteine elevations confirm atherosclerotic burden 2 Lipid evaluation is optimally assessed with a non-fasting sample 3 Fasting glucose and thyroid stimulating hormone levels should also be ordered 4 Lipoprotein electrophoresis is essential in the management of this patient 5 A clear supernatant following overnight refrigeration of a sample indicates chylomicronemia

3 Fasting glucose and thyroid stimulating hormone levels should also be ordered

A 35-year-old woman presents because of weight loss and palpitations. She lost 10 kg over 5 months despite having a good appetite. Her heart pounds and her hands tremble "all the time." She feels hot, is sweating profusely, and has difficulties going to and maintaining sleep; the slightest stimulus wakes her. Her job is suffering because of her nervousness, and her supervisor became concerned because she uses the bathroom 3 - 4 times a day in a need to move her bowels. She thinks that poor sleep quality and frequent bowel movements make her weak; she cannot climb stairs anymore and has to take a rest every 10 steps or so. Physical examination reveals a slim, anxious woman with pronounced stare, fine postural and tremor at rest, and slight proximal weakness. Her thyroid is diffusely enlarged and non-tender; her pulse is 100/min; and the rest of examination is within normal limits. Question What is the most likely diagnosis? 1 Hashimoto's thyroiditis 2 Toxic goiter 3 Grave's disease 4 Plummer's disease 5 Thyroid storm

3 Grave's disease

A 48-year-old man presents to the family practice clinic for evaluation of fatigue, weakness, and nausea. He reports that his symptoms have progressively worsened over the last 6 - 8 months. He reports fatigue despite adequate sleep; he is also experiencing an overall feeling of muscle weakness, nausea with occasional vomiting, a weight loss of about 12 pounds, headaches, and muscle aches. His wife thinks he appears tanned year-round, despite a lack of sun exposure. He admits feeling anxious and somewhat irritable, but he denies any major psychosocial or traumatic events surrounding onset of symptoms. Prior to the onset of his symptoms, he was healthy and active. His past medical history reveals no chronic medical conditions and no medication use; there is no history of surgery; he does not have any allergies. His family history is significant for thyroid disease in a sister and his mother; there is also a history of diabetes mellitus type I in a brother. He teaches high school, and he lives with his wife and children; he denies the use of tobacco, alcohol, and drugs. On physical exam, he is noted to be hypotensive and hyperpigmented. The remainder of his physical exam is normal. Several labs are performed, and the results are as follows: Urinalysis Normal Complete blood count Mildly decreased hemoglobin and hematocrit Comprehensive metabolic panel Mildly decreased sodium and elevated potassium; the rest is normal Adrenocorticotropic hormone (ACTH) Elevated Cortisol (morning level) Decreased ACTH stimulation test Decreased cortisol Question Once this patient's condition is stabilized and treated with the appropriate medication(s), what should be done to prevent making his condition worse (i.e., health maintenance recommendations)? 1 Avoid any sun exposure 2 Avoid phenylalanine-containing dietary products 3 Increase medication prior to any future surgery 4 Perform yearly renal ultrasounds 5 Switch to salt substitutes

3 Increase medication prior to any future surgery

A 55-year-old woman with a 15-year history of type II diabetes presents for follow-up of her diabetes. Her spot albumin/creatinine ratio was 100 mg/g 4 months ago and was confirmed at 100 mg/g yesterday. Her urinary analysis shows no cells, casts, or blood. Her creatinine is 0.7mg/dl, and her estimated glomerular filtration rate is 95 ml/min/1.73m2. Question What medication(s) should you prescribe to help prevent her progression from micro to macroalbuminuria and to help prevent progressive decline in glomerular filtration rate? 1 Potassium chloride 2 Calcium carbonate 3 Lisinopril 4 Sodium bicarbonate 5 Calcium citrate

3 Lisinopril

A 13-year-old boy has a 3-year history of type I diabetes mellitus without significant problems; he presents for an acute visit. The patient states his morning glucose readings have risen from an average of 100 mg/dL to over 200 mg/dL over the past 2 weeks. He is currently taking 25 units of glargine (Lantus) at bedtime and 8 units of aspart (Novolog) before meals. The patient states that he has been compliant with his insulin and diet. His mother states that he recently has been having nightmares and night sweats, but he denies any other complaints. ROS and physical exam are otherwise unremarkable. What is the patient most likely experiencing? 1 A tonic seizure 2 Diabetic ketoacidosis 3 Somogyi effect 4 Dawn phenomenon 5 The onset of puberty

3 Somogyi effect

A 21-year-old insulin-dependent diabetic college student is acutely agitated and is verbalizing expletives. Prior to admitting him to an acute psychiatry inpatient service and administering intra muscular chlorpromazine (Thorazine) or haloperidol (Haldol), for what should he be evaluated? 1 Hyponatremia 2 Hypokalemia 3 Hypocalcemia 4 Hypovolemia 5 Hypoglycemia 6 Hypomagnesemia 7 Hypothermia

5 Hypoglycemia

A 22-year-old woman is started on carbimazole for the treatment of her hyperthyroidism. She has been diagnosed with Graves' disease and has been symptomatic for the last 6 months. She is otherwise healthy and does not take any other medications. You receive a call 2 weeks later from the patient; she tells you that she has had a mild sore throat for the past 2 days and has been feeling like she is coming down with the flu. She states that the symptoms of her hyperthyroidism are a little bit better. Question What should you do? 1 Increase dose of carbimazole 2 Prescribe a small dose of thyroxine 3 Tell her to present ASAP for total and differential blood count 4 Prescribe antibiotics 5 Prescribed saltwater gargles and acetaminophen

3 Tell her to present ASAP for total and differential blood count uncommon, but well recognized, side effect of antithyroid medications is the potential to cause rapid agranulocytosis, characterized by a very low circulating neutrophil count

A 33-year-old woman presents with fatigue, weight gain, and non-specific aches and pains for the past year or so. She denies fever, cough, abdominal pain, dysuria, or visual changes, but she has had constipation recently. She feels dizzy on and off, and she grows increasingly tired with each passing day. Her weight gain of 20 pounds or so in the last year has made her depressed and tired. Her best friend repeatedly tells her that her voice is deeper and raspier on the phone. After further questioning, she claims that she has had quarrels with her husband and children regarding the thermostat in her house. She would like to keep it at 80°F, and they want it at 60°F in this month of May. On examination, she has a temperature of 96°F, pulse 56/min, and BP 110/70 mm of Hg. She is 5'3" tall, and her weight is 155 pounds. Lungs are clear, abdomen shows no abnormal findings, and heart sounds are regular. Her skin appears somewhat dry and scaly. Her hair is coarse. You order tests. Question What is the most important test at this point? 1 Metabolic panel 2 Complete blood count and peripheral smear 3 Thyroid stimulating hormone 4 FSH and LH 5 Lipid profile

3 Thyroid stimulating hormone

A 63-year-old diabetic woman is seen by her primary care physician. Despite having been an insulin dependent diabetic for over 20 years, her blood sugars remain poorly controlled. No amount of counselling seems to have made a difference to her attitude. At this visit, she complains of left-sided ear pain. She noticed it the previous night; she was unable to sleep with her head resting on the affected side. Since then, the pain has rapidly increased, and she feels feverish. The photograph shows the affected area at the time of the visit. Question What is the best next step in treatment of her condition? 1 Aggressive surgical debridement 2 High-dose crystalline penicillin 3 Intravenous clindamycin 4 Intravenous amikacin 5 Intravenous ceftazidime

5 Intravenous ceftazidime

What risk factor(s)/lipid class combination most closely identifies the need to institute pharmacotherapy? 1 An LDL cholesterol of >110; no history of coronary heart disease (CHD) 2 A total cholesterol of <200; hypertension (BP >140/90) 3 An HDL cholesterol of >60; cigarette smoking 4 An HDL of <40; age (men >45 yrs, women >55 yrs) 5 VLDL of <100; diabetes

4 An HDL of <40; age (men >45 yrs, women >55 yrs)

A 26-year-old woman wants to conceive over the next few months. She is married, has 1 child, and she and her husband have been using condoms and foam for contraception. Her past medical history is significant for hypothyroidism which is treated with levothyroxine (Synthroid) 0.125 mg PO per day. Her last thyroid-stimulating hormone (TSH) level, performed 3 months ago, was normal. Today, she presents with a 6-week history of amenorrhea. A urine pregnancy test is positive. You estimate that she is 6 weeks pregnant. What will she likely need? 1 A decrease in her levothyroxine (Synthroid) dose 2 Checking free T4 levels 3 Adding triiodothyronine 4 An increase in her levothyroxine (Synthroid) dose 5 Checking free T3 levels

4 An increase in her levothyroxine (Synthroid) dose

A 75-year-old woman presents with frequent leakage of her urine over the past several months; she is also experiencing frequent urinary infections. Leakage is sometimes "continuous", occurring both day and night. She also complains of tingling in her feet and hands, nausea, and a feeling of fullness after eating only a small amount of food. Her past medical history is significant for a 15-year history of diabetes mellitus type II, mild hypertension, and renal insufficiency stage 1. She takes metformin and ACE inhibitors. On examination, you find distended bladder and dysesthesia of stocking and glove pattern; the rest of the examination is within normal limits for her age. Question What is the most likely cause of her symptoms? 1 Pelvic floor muscle weakness 2 Detrusor underactivity 3 Kidney failure 4 Detrusor overactivity 5 Urinary tract infection

4 Detrusor overactivity

A 45-year-old woman presents with vaginal itching and irritation that did not resolve with over-the-counter medications. She has not previously sought medical attention for the symptoms. During review of systems, she admits to polyuria, polydipsia, and occasional dysuria, which she attributes to the vaginal irritation. She states she has not had lab work done in over a year, but the last time she did was at a health fair; she was told her fasting glucose was 119 mg/dl. On exam, you note that the patient is 62 inches tall and weighs 243 pounds. Her vital signs are within normal limits except for her blood pressure, which is 138/84 mm Hg. You find that she has white discharge in the vaginal canal; there is beefy-red surrounding skin and similar irritation under her breasts. Question Based on this patient's presentation, what do you suspect is the patient's most serious condition? 1 Obesity 2 Hypertension 3 Sexually transmitted infection 4 Diabetes mellitus 5 Mucocutaneous candidiasis

4 Diabetes mellitus

A 44-year-old obese woman presents with increased nighttime urination. She has never had issues with having an increased urge to urinate nocturnally before, and it is extremely bothersome to her. She states that she has been waking up at least 3 times a night despite lifestyle modifications designed to help reduce this number. The patient admits to increased fatigue, worsening blurry vision, and 2 vaginal yeast infections in a span of 3 months. Question What is the most likely diagnosis? 1 Hyperthyroidism 2 Hypothyroidism 3 Diabetes type I 4 Diabetes type II 5 Cushing's syndrome

4 Diabetes type II

A 35-year-old man with type I diabetes presents for an acute visit with uncontrolled blood sugars with high and low readings throughout the day and night. When he called to make this appointment, he was advised to bring in his blood sugar log and check a few 3:00 am blood sugars. He is currently on 40 units of NPH and 20 units of regular insulin before breakfast, and 20 units of NPH as well as 10 units of regular insulin before dinner. Time 7am 11 am 5 pm 11 pm 3 am 393 210 175 140 50 Question What is the most appropriate insulin change based on his average blood glucose readings? 1 Add 4 units of regular insulin before breakfast 2 Add 2 units of NPH insulin before breakfast 3 Add 2 units of NPH insulin before dinner 4 Eliminate 4 units of NPH insulin before dinner 5 Eliminate 2 units of regular insulin before dinner

4 Eliminate 4 units of NPH insulin before dinner The first step in managing insulin therapy is to eliminate low blood sugars.

A 45-year-old woman presents with a weight gain of 50 pounds; she attributes the weight gain to her hard-working lifestyle as a corporate attorney. She usually eats out and rarely exercises. She has a fasting blood glucose of 220 mg/dL and a urinary albumin/g creatinine of 40 mg. These are new findings since her visit 5 years ago. She has been following a high-protein diet, primarily consisting of animal proteins, for the past couple of days. Question What dietary and lifestyle interventions should be recommended due to this patient's blood glucose and urinary albumin findings? 1 Continue high-protein diet for weight loss and reducing proteinuria and begin exercising 2 Continue present high-protein diet for weight loss and glycemic control and begin exercising 3 Continue present high-protein diet for weight loss, glycemic control, and proteinuria reduction 4 Encourage a low-calorie diet, modest protein and carbohydrate restriction, and exercise 5 Discontinue present diet and recommend a low-fat and extremely low-protein diet

4 Encourage a low-calorie diet, modest protein and carbohydrate restriction, and exercise

A 17-year-old girl presents because her heart is beating "funny". She describes episodes of a racing intense heartbeat. Her mother notes that the girl has seemed down and emotional. There has been significant weight loss over the past year. On physical examination, there is exophthalmos and a fine tremor on extension of the hand. Her pulse rate is about 100/minute. What is the most likely diagnosis? 1 Anorexia nervosa 2 Bipolar mood disorder 3 Cocaine abuse 4 Hyperthyroidism 5 Stimulant abuse

4 Hyperthyroidism

A 35-year-old woman presents with a 2-year history of the gradual onset of nervousness and fatigue. She has lost 15 lbs. in the past year despite an increase in appetite. Her menses have become scant with frequent intermenstrual spotting, and she feels that she constantly prefers a cooler environment than those around her. On physical examination, she has a heart rate of 100/min with normal blood pressure. A fine tremor of the fingers is noted. The skin is warm, moist, and has a smooth texture. The thyroid is diffusely enlarged to palpation. A lid-lag sign is easily demonstrable. Question What is a common complication of the patient's disease? 1 Hepatitis 2 Interstitial pneumonia 3 Peptic ulcer disease 4 Infiltrative ophthalmopathy 5 Hemolytic anemia

4 Infiltrative ophthalmopathy The patient suffers from Graves' disease

A 68-year-old man presents with acute chest pain. He has a long-standing history of diabetes mellitus (20 years) and hypertension (10 years). He has no history of coronary artery disease, but has hyperlipidemia. His medications include atenolol 50 mg daily, metformin 1000 mg twice daily, aspirin 80 mg daily, and simvastatin 40 mg daily. On arrival, he has a temperature of 99°F, a pulse of 106 bpm, BP 100/60 mm Hg, and a respiratory rate of 26/min. His lungs have fine crackles bilaterally, heart sounds are heard with tachycardia, and abdomen is essentially normal. His labs show the following: Test Value WBC 11,000µL Sodium 132 mEq/L Potassium 3.8 mEq/L Chloride 102 mEq/L Serum Bicarbonate 12 mEq/L Blood Sugar 258 mg/dL Serum Ketones Absent BUN 38 mg/dL Creatinine 2.1 mg/dL Arterial Blood Gas pH 7.1 EKG ST segment elevation Troponin 7.0 ng/mL CK-MB 450 u/L The patient is diagnosed with acute myocardial infarction. Question What is the metabolic abnormality in this patient? 1 Nonketotic hyperglycemic hyperosmolar coma 2 Diabetic ketoacidosis 3 Uremic acidosis 4 Metformin-induced lactic acidosis 5 Renal tubular acidosis

4 Metformin-induced lactic acidosis

A 23-year-old woman is brought to the office due to her "heart racing". Her episodes have been intermittent over the past 2 weeks. She reports feeling tired, and she has not worked for 2 days. She says she had 'the flu' about a month ago and has not quite recovered. On examination, her pulse is 102/min, BP 110/80, and her palms feel sweaty and shaky. All other systems appear to be normal. Her lab investigations are given below: Creatinine: 0.9 mg/dl AST: 45 IU/dl ESR: 68 mm/hr Hemoblobin: 11.9 g/dl TSH: 0.01 mIU/mL T3: 5 mcg/dL T4: 160 mcg/dL Her radioiodine uptake scan shows diffusely reduced uptake throughout the gland. Question What is the best initial therapy? 1 Propylthioruacil 2 Radiolabeled Iodine ablation 3 High dose prednisone 4 NSAIDs 5 Levothyroxine

4 NSAIDs

A 42-year-old Hispanic man presents because his employee health fair lab results returned with several 'out of normal' range results. He is an established patient in your practice; you have seen him 4 times for illness or minor injury over the past 10 years. He reports that he is in generally good health and feels well; he does not see any other healthcare providers. A summary of his past medical history includes: Medications: occasional over-the-counter ibuprofen for joint pain Allergies: none Surgical history: open reduction of left ankle at the age of 22 years Medical history: mild osteoarthritis Social history: patient denies the use of tobacco or illicit drugs. He drinks 3 - 4 beers per week. He is married and has 5 kids; he works in industrial hygiene at a lab facility. He plays rugby on the weekends as a hobby. Family history: no chronic diseases are known to the patient. His vital signs at check-in were all in normal ranges. This patient's laboratory results from the health fair are shown in the chart. Complete blood count (CBC) WBC 6.1 3.6 - 9.0 K/μL RBC 4.78 4.18 - 5.22 M/ μL Hemoglobin 15.4 12.9 - 15.5 g/dL Hematocrit 45.2 34.6 - 50.1% MCV 94.6 80.0 - 100.0 fL MCH 32.2 27.0 - 34.0 pg MCHC 34.1 30.0 - 37.0 g/dL RDW 11.7 11.0 - 17.0% Platelets 462 140 - 440 K/μL MPV 9.9 6.5 - 12.0 fL WBC differential Normal Complete Metabolic Panel (CMP) Sodium 132 134 - 144 mmol/L Potassium 3.3 3.4 - 4.9 mmol/L Chloride 100 100 - 109 mmol/L HCO3 26 20 - 31 mmol/L Glucose 94 70 - 99 mg/dL Bun 20 7 - 18 mg/dL Creatinine 1.1 0.6 - 1.2 mg/dL Calcium 9.9 8.8 - 10.5 mg/dL Albumin 3.5 3.5 - 5.0 g/dL Total Protein 6.3 6.4 - 8.2 g/dL AST (SGOT) 21 15 - 37 U/L ALT (SGPT) 17 5 - 43 U/L Alk Phosphatase 55 50 - 136 U/L Total Bilirubin 0.8 0.1 - 1.2 mg/dL Anion Gap 6 6 - 16 mmol/L eGFR >60 >60 mL/min/1.73m2 Cholesterol 226 </=200 mg/dL Triglyceride 864 </=150 mg/dL HDL 42 40 - 59 mg/dL LDL Unable to calculate VLDL 37 6-35 mg/dL TSH 1.960 0.500 - 4.700 uIU/mL Based upon the history and test values presented, what is this patient's most significant risk? 1 Dehydration 2 Hemorrhage 3 Malnutrition 4 Pancreatitis 5 Renal failure

4 Pancreatitis

An 18-year-old woman presents with nausea, vomiting, drowsiness, and abdominal pain. She has Kussmaul respirations, ketotic breath, dry tongue, and loss of skin turgor. Her laboratory studies show the following results: sodium, 126 mEq/L; potassium, 3.1 mEq/L; bicarbonate, 8 mEq/L; chloride, 98 mEq/L, glucose, 320 mg/dL; BUN, 26 mg/dL; creatinine, 1.0 mg/dL; pH 7.02; pCO2, 13 mm Hg; and pO2, 86 mm Hg. Question In addition to intravenous fluid administration, what therapy should be administered as part of initial treatment? 1 Calcium 2 Magnesium 3 Phosphate 4 Potassium 5 Bicarbonate

4 Potassium Diabetic ketoacidosis is marked by an absolute insulin deficiency resulting in metabolic acidosis, ketonemia, and hyperglycemia. It is most commonly observed in patients with type 1 diabetes as a result of noncompliance with insulin therapy.

A 45-year-old man presents with severe pain in the left flank that began in the morning; it comes and goes, lasts 20 minutes, and has an intensity of 10/10. He denies fever or urinary symptoms. He has a cousin with pancreatic cancer. The physical exam (PE) is negative. Laboratory analysis shows UA with uncountable erythrocytes, and high plasma levels of PTH. Question What is the most probable diagnosis? 1 Li-Fraumeni syndrome 2 Von Hippel-Lindau disease 3 Turcot syndrome 4 Cowden syndrome 5 MEN1

5 MEN1

A 72-year-old African-American man is brought to the emergency department by his family because of disorientation. According to the family, he has become progressively more withdrawn, apathetic, and has been complaining of progressive nausea, vomiting, anorexia, drowsiness, and lethargy during the last few months. His past medical history includes type-2 diabetes, controlled with diet and metformin, and an uncomplicated appendectomy 15 years ago. Vital signs are within normal range. On physical examination, he is disheveled, disoriented, drowsy, and slightly dehydrated. Heart rate is regular, and peripheral pulses are symmetric and normal on palpation. The thyroid gland is normal to palpation, and there are no enlarged cervical lymph nodes. Lung fields are clear to auscultation. A lab workup reveals the following: Ht. 36% Hb 13 g/dL MCV 86 fl, platelets 310,000 /mm3, Na+ 145 mEq, K+ 4.9, Cl- 101, Ca2+ 14.1, Glucose 91 mg/dL, BUN 8 mg/dL, and creatinine 0.8 mg/dL. What is the most appropriate next step in management? 1 Hemodialysis 2 Mithramycin 3 Calcitonin 4 Saline + furosemide 5 Biphosphonates

4 Saline + furosemide

A 40-year-old woman presents for check-up. She is married with 2 sons, and she experiences occasional constipation; she attributes it to her diet. She mentions having mild anxiety. She does not smoke; she consumes alcohol only recreationally, and she has a body weight of 85 kg. She is well nourished and communicates well. Lung, cardiac, abdominal, and neurological examinations are unremarkable. Her thyroid is normal in size and consistency. Her menses are normal, and her drug history is negative, except for "hormone pills" for contraception. Her family history is remarkable for a mother with hypothyroidism and osteoporosis. Question What screening option is appropriate for this woman at present? 1 Follow-up 2 Free T3 assay 3 Total T4 assay 4 Serum TSH assay 5 Total T4 and T3 resin uptake assays

4 Serum TSH assay The American Thyroid Association recommends that adults, particularly women, high-risk individuals, and those with symptoms and signs attributable to thyroid dysfunction, should be screened for thyroid dysfunction by measuring serum TSH concentration beginning at the age of 35 years

A 70-year-old woman presents with a 1-week history of palpitations, dyspnea, and generalized weakness. She also gives history of decreased oral intake and weight loss. The patient has no significant previous medical history. On admission, the patient is afebrile. Pulse is 130/min, BP is 100/68 mm Hg, and RR is14/min. Chest X-ray is normal, and electrocardiogram shows an atrial fibrillation. Skin appears warm and smooth. Question What is the next diagnostic step that would be useful in management? 1 Carcinoembryonic antigen (CEA) test 2 Gastroscopy 3 Colonoscopy 4 Thyroid tests 5 Adrenal functional tests

4 Thyroid tests

A 23-year-old man, diagnosed with type 1 diabetes 5 years ago, presents for a regular examination. Upon physical examination, temperature is 98.1° F, blood pressure is 120/80 mm Hg, and there are no signs of edema. He explains that recently he has been noticing that his urine seems a little darker and foamy, but he has no discomfort while urinating. Blood tests indicate an A1C level of 6.7%. Question What test should be ordered? 1 Complete blood count 2 Glucose tolerance test 3 Serum creatinine measurement 4 Urine albumin measurement 5 Urine culture

4 Urine albumin measurement

A 47-year-old man presents for his annual physical exam. His past medical history is not significant, and he is not currently on any medications. He consumes 2 beers weekly and does not smoke. His blood pressure is normal at this visit. His primary care physician orders a fasting lipid panel with the following results: Triglyceride: 135 HDL: 50 LDL: 220 Question Ico-delete Highlights In addition to diet and exercise, what medication should be started on this patient? 1 Cholestyramine 2 Fenofibrate 3 Nicotinic acid 4 Simvastatin 5 Ezetimibe

4. Simvistatin

A 38-year-old man presents with fatigue, dry mouth, and passing large amounts of urine. He describes his urine as light in color and non-odorous. He says he never had this before. He has always been healthy, and he has never been hospitalized before. During a routine pre-employment screening, his serum electrolytes were investigated; his sodium level was slightly above normal. At that time, he was reassured that it was due to slight dehydration. He was advised to repeat the test after 3 months. When he repeated it about a week ago, it showed more of an increase. He takes vitamin supplements and sometimes uses energy drinks. To avoid going to the bathroom too often, he tries to restrict fluid intake to a minimum, but he says it has never helped. Question What is the most appropriate next step in the management of this patient? 1 Serum osmolarity 2 Brain MRI 3 Urine osmolarity 4 DDAVP (desmopressin test) 5 Blood glucose level

5 Blood glucose level Diabetes mellitus (DM) should be excluded first in all patients with polyuria. Therefore, checking blood glucose level is the next best step.

A 42-year-old man presents with fatigue, polyuria, and polydipsia for the past 2 - 3 months. He has a history of hypertension and obesity. He is on 10 mg of amlodipine daily and 75 mg of aspirin daily. His family history is significant for diabetes mellitus in the patient's mother and 2 siblings. On exam, the patient is afebrile; he has a blood pressure of 130/80 mm Hg; he has a weight of 220 lbs, and his height is 66 inches. He has no pallor, icterus, or lymphadenopathy. Lungs are clear to auscultation, and heart sounds are regular. The abdomen is normal, and there is minimal pitting pedal edema. Initial fundus exam is normal. Tests are done, including fasting blood glucose on 2 different days, a basic metabolic panel, and lipid profile. Fasting blood glucose was 136 mg/dL on the 1st day and 140 mg/dL on the 2nd. He is diagnosed with type II diabetes mellitus. Question What is the best strategy for treatment of this patient? 1 Diet control, weight loss, and exercise for 6 - 12 months; then, follow up tests should be performed for further treatment 2 Diet, weight loss, and exercise indefinitely if symptoms resolve 3 Oral hypoglycemic therapy with a sulfonylurea; tests should be repeated every 3 months, and a 2nd agent should be added if fasting blood sugar still above 140 mg/dL 4 Diet, weight loss, exercise, and monotherapy with metformin for 6 months, followed by repeat tests and adjustment of medication dose or addition of sulfonylurea 5 Diet, weight loss, and exercise for 4 - 6 weeks; then, if fasting blood sugar level remains above 126 mg/dL, add metformin

5 Diet, weight loss, and exercise for 4 - 6 weeks; then, if fasting blood sugar level remains above 126 mg/dL, add metformin A newly diagnosed patient with type II diabetes mellitus should be given a trial of therapeutic lifestyle changes

A 33-year-old woman presents with weight loss in spite of a hearty appetite. At first glance, the physician notices her large eyes. She gives a history of increased anxiety over the last few months; it has been associated with palpitations and diaphoresis. During the examination, the physician notes tachycardia, hypertension, sweaty palms, and trembling outstretched hands. There is a diffuse swelling in the neck with a bruit heard on auscultation. Question What is the most likely diagnosis? 1 Hashimoto's thyroiditis 2 Hypothyroidism 3 Parathyroid adenoma 4 Lateral aberrant thyroid 5 Graves' disease 6 Hyperthyroidism

5 Graves' disease

A 41-year-old man presents for a physical. He has not had a routine physical in a couple of years. Upon taking a review of systems, you become suspicious that the patient is not present for routine health maintenance alone. The patient admits to various abnormal symptoms that result in the patient receiving an order slip for a 24-hour urine study looking for vanillylmandelic acid (VMA), catecholamines, and metanephrines. What triad of symptoms indicated a need for this particular 24-hour urine study? 1 Dry skin, fatigue, and shortness of breath 2 Fatigue, flushing, and constipation 3 Headache, dry skin, and nausea 4 Flushing, constipation, and nausea 5 Headache, palpitations, and diaphoresis

5 Headache, palpitations, and diaphoresis

A 59-year-old woman presents for a routine annual physical. She is a housewife who does not smoke or drink, and her only significant past medical history is for an appendectomy and radiation treatment for acne as a child. She is post-menopausal, but she uses natural supplements rather than hormone replacement. She is not on any prescription medications. She completed some routine lab work prior to the office visit. The results are entirely within normal limits, including cholesterol panel, glucose, TSH, and T4. Her only complaints are recent dysphagia and sensation of fullness in her neck. Physical examination reveals a large nodule right lobe of patient's thyroid. The patient is referred to an endocrinologist and undergoes an ultrasound of the thyroid, which is followed by a thyroid scan. The results confirm a 1.7cm solid nodule on ultrasound that is deemed 'cold' on thyroid scan. Question Prior to scheduling a fine needle aspiration and based on the information you have, what is the the most likely diagnosis? 1 Hashimoto's thyroiditis 2 Medullary thyroid carcinoma 3 Parathyroid cyst 4 Graves' disease 5 Papillary thyroid carcinoma

5 Papillary thyroid carcinoma

A 55-year-old man presents for a follow-up on recent cholesterol tests. He has a past medical history of 2 coronary stents placed 3 days ago after presenting to the emergency department with chest pain and a 40 pack-year history of smoking (he quit smoking 2 years ago). He was not on any medications when he presented to the ER. Cholesterol tests reveal: total cholesterol 200 mg/dL; LDL 100 mg/dL; HDL 40 mg/DL; and triglycerides 395 mg/dL. Question What is the most appropriate treatment to reduce future cardiovascular risk in this patient? 1 Fibrates 2 Fish oil 3 Nicotinic acid 4 Plasmapheresis 5 Statin

5 Statin

A 35-year-old woman presents with weight loss, tremor, and palpitations. She also feels hot, is sweating, and has sleep difficulties and frequent arousals, in addition to frequent bowel movements (3-4 times a day), nervousness, and weakness. Physical examination reveals a slim anxious female with pronounced stare, fine postural and tremor in rest, and slight proximal weakness. Her thyroid is diffusely enlarged and non-tender; her pulse is 100/min; and the rest of examination is within normal limits. Her TSH is low, and free T4 is high. Question What is the most accurate diagnostic test for hyperthyroidism in this patient? 1 MRI of pituitary gland 2 Free T3 3 Fine needle biopsy 4 Color Doppler flow 5 Thyrotropin receptor antibody assay

5 Thyrotropin receptor antibody assay

There are three major carrier proteins for T3 and T4. More than 99% of these transport globulins are responsible for binding and transporting T3 and T4. What transport binding is responsible for the most transportation of T3 and T4? 1 Immunoglobulin A 2 Immunoglobulin B 3 Albumin 4 Thyroxine-binding prealbumin (TBPA) 5 Thyroxine binding globulin (TBG)

5 Thyroxine binding globulin (TBG)

An 8-year-old child presents with acute fever; there is redness of the skin in the neck area. The thyroid gland is extremely tender to palpation. Question Based on the most likely diagnosis, what test is most likely to be abnormal? 1 Serum T4 concentration 2 Serum TSH measurement 3 T3 resin uptake 4 24-hour uptake of radioactive iodine 5 WBC

5 WBC The symptoms are highly suggestive of acute suppurative thyroiditis, a bacterial infection of the thyroid