Old Q&A – Endocrinology

The correct answer is C. This patient has impotence, loss of libido, and galactorrhea related to hyperprolactinemia. The most common cause of this in men is probably medication induced, however, he is on no medications. The next main thing to rule out is a prolactin secreting microadenoma by an MRI of the brain.

Bromocriptine (choice A) may end up being the treatment of choice for this patient if a microadenoma is found. However the diagnosis should be made prior to treatment. If bromocriptine therapy fails to relieve symptoms, or if the adenoma grows/begins causing other symptoms, referral to neurosurgery to evaluate for transphenoidal resection would be warranted.

There is no indication for a mammogram (choice B) or an MRI of the lumbar spine (choice D) in this case.

Sildenafil (choice E) also may end up being helpful in this case for the patient’s symptoms. However, again making the underlying diagnosis is the most appropriate first step in the work up.

The correct answer is C. This patient is a type I diabetic with mild hypertension. The Joint National Committee recommends ACE inhibitors, such as enalapril, as first-line treatment of hypertension in diabetics. Multiple studies have proven that ACE inhibitors prevent microalbuminuria and thus preserve renal function.

Amlodipine (choice A) is a calcium channel blocker commonly prescribed for hypertension. However, it has not been proven to have the renal protective properties of ACE inhibitors. Therefore, choosing amlodipine is incorrect.

Atenolol (choice B) is a beta-blocker that is often used as a first-line agent in non-diabetics. However, beta-blockers should be avoided in patients with type I diabetes, asthma, and depression. Additionally, the patient’s low heart rate would contraindicate the use of a beta-blocker.

Furosemide (choice D) and hydrochlorothiazide (choice E), a thiazide diuretic and a loop diuretic, are often used as initial agents in the treatment of hypertension due to their efficacy and cost effectiveness. However, the renal protective benefits of an ACE inhibitor make enalapril a more appropriate choice for this patient.

The correct answer is D. Nervousness, tremor, heat intolerance, and weight loss are classic signs and symptoms of hyperthyroidism. Hyperthyroidism is a well known cause of atrial fibrillation. This arrhythmia will respond to the treatment of the underlying endocrine abnormality. A serum thyroid stimulating hormone (TSH) level will be abnormally low in patients with hyperthyroidism and is a very specific test for this disorder.

A chest x-ray (choice A) is not a useful study in the evaluation of atrial fibrillation in the setting of hyperthyroidism. There is no reason to suspect other primary lung diseases in an otherwise healthy young male to warrant a chest x-ray.

A CT of the head (choice B) will not provide information about the etiology of the patient’s atrial fibrillation. He has a distant history of surgical resection of a benign brain tumor and there is no reason to suspect metastatic disease. There is no association between primary brain pathology and atrial fibrillation.

An exercise tolerance test (choice C) is an examination to evaluate for cardiac ischemia or past infarct. This study is performed by having a patient exercise on a treadmill while wearing the electrocardiogram leads. A continuous EKG is performed during exercise to monitor for signs of ischemia. Cardiac ischemia is a very common cause of atrial fibrillation. However, there is no reason to suspect an ischemic etiology of this arrhythmia in a young, otherwise healthy patient.

A ventilation/perfusion scan (choice E) is a good diagnostic study for the evaluation of a pulmonary embolism. A pulmonary embolism is a known cause of atrial fibrillation. Although recent surgery and hospitalization does put the patient at increased risk for thromboembolic disease, he does not have shortness of breath, chest pain, or other classic symptoms of a pulmonary embolism. Young and healthy patients do develop thromboembolic disease in the setting of pelvic and lower extremity trauma, and prolonged hospitalization or bedrest.

The correct answer is B. This patient is most likely experiencing the symptoms of hypoglycemia, which should be treated with intravenous glucose until the patient can eat a meal. There are two categories of symptoms associated with hypoglycemia: the autonomic response and the neuroglycopenic response. The former is due to excessive secretion of epinephrine/norepinephrine and consists of tremor, palpitations, sweating, hunger, and anxiety. The latter is caused by central nervous system dysfunction and includes dizziness, headache, blurry vision, confusion, abnormal behavior, and a loss of consciousness. Symptoms do not usually occur until the blood glucose falls below 45 mg/dL. Causes of hypoglycemia include postprandial hypoglycemia, fasting hypoglycemia, insulinomas, and factitious hypoglycemia.

This patient should not have a glass of orange juice (choice A) right now because he is losing consciousness and therefore cannot eat or drink. The initial treatment for hypoglycemia with both autonomic and neuroglycopenic symptoms is intravenous glucose. This can be discontinued when the patient is able to eat and drink.

Administration of isotonic saline, intravenously (choice C) is part of the initial treatment for diabetic ketoacidosis. 5% glucose solutions should be added when the plasma glucose level falls below 300 mg/dL. This would be inappropriate for a hypoglycemic because they need glucose. The symptoms of DKA include increased urination, thirst, abdominal pain, mental status changes, anorexia, nausea, and vomiting. The patient in this case does not have these symptoms.

Naloxone would reverse this patient’s symptoms (choice D) if they were caused by an opioid overdose, not hypoglycemia. Naloxone is an opioid antagonist that competes for the opioid receptors and will block the effects of heroin and other opioids. Symptoms of an opioid overdose include miosis, respiratory depression, coma, hypotension, and bradycardia. The patient in this case does not have these symptoms.

Physostigmine would reverse this patient’s symptoms (choice E) if they were caused by anticholinergic poisoning, not hypoglycemia. The symptoms of anticholinergic poisoning can occur with overdoses of antihistamines, atropine, tricyclic antidepressants, and scopolamine, and include hyperthermia, vasodilatation, decreased salivation, mydriasis, delirium, and hallucinations. The girlfriend did not say that he took any medications. The fact that these symptoms occurred a few hours after a meal and that he has had similar episodes in the past and his physical examination did not reveal mydriasis or hyperthermia makes his condition more consistent with hypoglycemia than anticholinergic poisoning.

The correct answer is A. In the evaluation of weight gain, the first step is to perform a thorough history and physical examination. If the patient tells you that they have not really had a change in appetite and have had a recent weight gain, you need to ask about medications, such as tricyclics, steroids, and antipsychotics and about smoking cessation and psychiatric disorders. This patient appears fidgety, which may be consistent with smoking cessation. Smoking cessation is often associated with a small weight gain (5-10 lbs), but it can lead to more dramatic weight gain in others. Before you perform any expensive and unnecessary diagnostic studies, you should first perform a detailed history.

Determining thyroid stimulating hormone levels (choice B) is appropriate in the evaluation of weight gain if there is a negative drug history, no recent smoking cessation, and a normal biochemical profile. Since hypothyroidism is part of the differential diagnosis for weight gain, you should consider it early in the work-up, but a biochemical profile should be performed first.

The initial work-up for weight gain is a detailed history, including medication and drug use and recent smoking cessation. If those are negative, then a biochemical profile (choice C) is indicated. A biochemical profile may indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes will most likely lead to an elevated glucose, while Cushings is sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis, hyperglycemia, and hypercholesterolemia.

A dexamethasone suppression test (choice D) is part of the initial evaluation of Cushing syndrome. You should first perform a complete history and if negative for such things as drug history, recent smoking cessation, and a psychiatric disorder, you should then order a biochemical profile. A dexamethasone suppression test should be ordered if the biochemical profile is suspicious for Cushing syndrome (hypokalemia, hypochloremia, metabolic alkalosis, hypercholesterolemia, and hyperglycemia).

Referring her to a nutritionist (choice E) is inappropriate at this time. The case says that the patient has had weight gain with no change in appetite or eating habits. She requires a thorough history and examination, and if negative, an evaluation for a medical condition such as Cushing syndrome, diabetes mellitus, thyroid disease (even though this is usually associated with a poor appetite), and fluid overload. A nutritionist may be valuable later if the complete evaluation is negative and you determine that she has poor eating habits. Obviously in that case you should try to help her with her dietary habits, but if you are unsuccessful, a nutritionist may be helpful.

The correct answer is A. Scleredema, candidiasis, necrobiosis lipoidal diabeticorum (NLD) is correct, because these three are all commonly associated with diabetes. Scleredema is a connective disorder with sudden onset of marked, nonpitting, symmetric induration of the posterior and lateral aspects of the neck spreading to shoulders, upper back, and proximal arms. The indurations are of wood-like consistency. Erythematous papular eruption occurs during the early stage of the disease. A syndrome has been recognized consisting of scleredema of long duration, obesity, maturity onset, latent or overt diabetes, and high incidence of cardiovascular disease. Candida albicans flourishes in the recesses created by redundant skin folds. Exacerbating factors may include diabetes mellitus, systemic medications, nutritional factors, and diminished salivary function. NLD is relatively asymptomatic, and is characteristically found on the anterior and lateral lower legs. They may also be present on the face, arms, and trunk. They begin as small, red nodules that enlarge to a plaque with irregular, flattened and eventually depressed atrophy. NLD seems to be a marker for diabetes.

Stasis dermatitis (choice B) is incorrect because classical stasis dermatitis appears on the medial surface of lower extremities with hyperpigmented patches mixed with occasional erythematous plaques. Often times, one can appreciate tortuous enlarged varicose veins.

Tinea corporis (choice C) is incorrect because it generally presents with erythematous annular plaques, with central clearing and no satellite lesions.

Scleroderma (choice D) and (choice E) is incorrect, because this is a connective disorder associated with the tightening of the skin, difficulty swallowing, telangiectasia, calcinosis, sclerodactyly, and other systemic involvement.

The correct answer is A. This patient has symptomatic hypercalcemia. The most likely etiology in this patient is hyperparathyroidism. This diagnosis is made by checking PTH levels. Since her calcium is elevated, a normal or high PTH level is inappropriate and therefore would help confirm the diagnosis.

Vitamin D (choice B) intoxication is typically secondary to patients taking large amounts of vitamin D (often for treatment of hypoparathyroidism). The treatment is to discontinue vitamin supplementation and recheck levels. This patient denied taking over-the-counter medications or vitamins.

Ordering a TSH (choice C) is never a bad idea in a patient with a variety of vague complaints since thyroid disease is very common and because it can explain these symptoms. In this patient, you would expect to find hypothyroidism based on her symptoms but an elevated serum calcium is more likely explained by hyperthyroidism secondary to increased bone turnover. Therefore, a PTH level would more likely lead to the correct diagnosis.

CT scanning of the neck (choice D) is very sensitive for parathyroid disease but it is not meant to be used as a screening test for hyperparathyroidism. Rather, the diagnosis is made by checking serum calcium and PTH levels.

Multiple myeloma is a common disease and can cause hypercalcemia as well. A serum protein electrophoresis (choice E) is helpful in making this diagnosis by demonstrating a monoclonal spike in the beta or gamma globulin region. Our patient lacks anemia, renal disease, or significant back pain which makes multiple myeloma less likely.

The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating bone resorption. Serum calcium levels normalize when the patient becomes euthyroid. Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism and should be investigated further.

Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and parathyroid hormone levels, normal or elevated urine calcium excretions, and low or normal plasma concentration of phosphates.

Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with solid tumors, including lung carcinoma, breast carcinoma, and squamous cell carcinoma of the head and neck. The hypercalcemia is thought to be caused by parathyroid hormone related protein secreted by the tumor. Patients with hematological malignancies may also have increased serum calcium levels, but this is thought to be due to cytokines causing increased osteoclastic activity in the bone.

Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine analysis shows protein in urine in multiple myeloma patients.

Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum phosphate would likely be depressed. In this patient, although the calcium levels are elevated, the phosphorus levels are high normal.

The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating bone resorption. Serum calcium levels normalize when the patient becomes euthyroid. Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism and should be investigated further.

Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and parathyroid hormone levels, normal or elevated urine calcium excretions, and low or normal plasma concentration of phosphates.

Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with solid tumors, including lung carcinoma, breast carcinoma, and squamous cell carcinoma of the head and neck. The hypercalcemia is thought to be caused by parathyroid hormone related protein secreted by the tumor. Patients with hematological malignancies may also have increased serum calcium levels, but this is thought to be due to cytokines causing increased osteoclastic activity in the bone.

Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine analysis shows protein in urine in multiple myeloma patients.

Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum phosphate would likely be depressed. In this patient, although the calcium levels are elevated, the phosphorus levels are high normal.

The correct answer is E. The most appropriate acute treatment of hypercalcemia is hydration followed by a forced diuresis. It is important to hydrate patients prior to administering the diuretic since most patients with this condition are hypovolemic from hypercalcemia induced nausea/vomiting and diabetes insipitus.

Administration of albumin (choice A), albeit a binder of serum calcium, has no role in the management of hypercalcemia.

Administration of dextrose followed by insulin (choice B) is one of the treatments of choice for acute hyperkalemia. It has no role in the management of hypercalcemia.

Administration of magnesium sulfate (choice C) has no role in the management of hypercalcemia.

Administration of pamidronate (choice D), a bisphosphonate which can decrease bone resorption, can be used in the chronic management of hypercalcemia, but has no role in its acute management.

The correct answer is C. This patient is suffering from diabetic ketoacidosis (DKA) caused by a severe deficiency of insulin. Clinical symptoms include coma, rapid and shallow breathing, high serum glucose levels, and metabolic acidosis. The immediate management of this patient includes intravenous fluid replacement and insulin infusion. When laboratory results return, electrolyte imbalances must also be corrected.

A chest x-ray (choice A) would be complementary to a complete the evaluation of any comatose patient. In this patient with a picture of diabetic ketoacidosis, a chest x-ray would be a secondary concern. The first priority is intravenous fluid replacement and insulin therapy.

Endotracheal intubation (choice B) is not necessary at this point as the patient has a normal oxygen saturation. Adequacy of respiration will need to be reassessed when the arterial blood gas results are available. The first priority is intravenous fluid replacement and insulin therapy.

Methadone (choice D) is used to treat heroin dependency.

A pulmonary artery catheter (choice E) is not yet necessary as the patient is at the present time hemodynamically stable. The first priority is intravenous fluid replacement and insulin therapy.

The correct answer is B. All three conditions show a lowering of cholesterol levels and the p-values indicate statistically significant differences among all three groups. However, the magnitude of the differences among the groups means that these differences are not clinically significant. Changes of 1 or 2 points in cholesterol levels are unlikely to be clinically meaningful. Because dietary change provides a notable lowering of cholesterol levels and avoids the possible side effects of the drug, this is the therapeutic option that gives the best benefit/risk ratio. Note that, of course, the physician should discuss with the patient his concerns that diet alone is not sufficient and explain the reasoning for this decision in detail.

Because there is no difference between the effects of dietary change or taking the drug, the patient can choose which one he prefers (choice A), taking the drug by itself has sufficient clinical merit, so that dietary change is not required (choice D), taking the drug either with or without dietary change has sufficient clinical effect to merit giving the patient a prescription (choice E), and the drug should be taken, but only in conjunction with dietary change (choice F) are all incorrect because the three groups are statistically significant; however, not clinically significant.

Studies found on the Internet are not a good source of information for making treatment decisions (choice C) is incorrect, because although everything on the Internet cannot be taken at face value, there are a number of excellent sites that publish valid, important medical information. The fact that the article was from the Internet, by itself, does not invalidate the article as a source of information.

The results of this study may not apply to this patient and a 3-month trial dosage of the drug should be given to see what effect it has (choice G) is incorrect, because although the patient may have particularities which make the effects on him different than the published study, the study results should be taken as accurate, unless and until an individual patient’s experience proves differently. Otherwise, all research would be useless and every drug would have to be tested on every patient.

The correct answer is E. Yearly eye exams by an ophthalmologist are recommended for all patients with type 2 diabetes mellitus beginning at the time of diagnosis.

Good visual acuity is not a predictor of the presence or absence of diabetic retinopathy (choice A).

Funduscopic exams (choice B) should be a part of a primary care physician’s evaluation of a patient with diabetes mellitus; however, the standard of care for diagnosis and treatment of diabetic retinopathy is under the care of an ophthalmologist.

Young patients who are newly diagnosed with type 1 diabetes may delay ophthalmology consultation for 5 years in the absence of visual complaints, but this does not apply to type 2 patients (choice C).

Good control of diabetes is important in preventing diabetic retinopathy; however, some patients will have diabetic retinopathy despite excellent control (choice D). Furthermore, diabetic patients are more likely to have other ocular diagnoses such as cataracts and glaucoma that are more easily diagnosed and managed by an ophthalmologist.

The correct answer is C. The target for lowering serum glucose is approximately 50-100 mg/dL/hour. More aggressive lowering of the serum glucose can result in cerebral edema. This is because the CSF glucose decreases more slowly than the serum glucose. If the serum glucose is lowered too rapidly, the CSF fluid is relatively hypertonic compared to the serum. Therefore, water will enter the CSF creating edema.

Arterial thrombosis (choice A) occurs with increased frequency in DKA. This can manifest as MI, ischemic limbs, or stoke. The fact that this patient has papilledema suggests that edema is more likely than stroke. This patient’s age also makes stroke less likely.

Toxic screening for drugs should be part of the initial evaluation of a patient with altered mental status. This patient has an anion gap acidosis with an elevated glucose and likely does have DKA. Therefore, a toxic drug screen (choice B) is not the best answer.

Normal saline (choice D) is an appropriate solution for rehydration in this patient. Although the patient’s sodium is 129 mEq/dl on admission, when corrected for the elevated glucose, the sodium is 139 mEq/dL. Remember that these patients are very dehydrated on admission and need to be volume resuscitated.

Lactic acidosis (choice E) can occur in patients with DKA from prolonged dehydration, infection, or tissue hypoxia. One would suspect that if this patient had a lactic acidosis on admission that it would correct with proper DKA management. You would not expect brain herniation from lactic acidosis.

The correct answer is A. This patient has type II (adult-onset) diabetes, which has been diagnosed by a fasting glucose over 200 mg/dl and classic symptoms, including weight loss, blurred vision, and polyuria. The class of drugs known as thiazolidinediones, which includes rosiglitazone (Avandia) and pioglitazone (Actos) are often used as initial monotherapy. The mechanism of action is through enhancing insulin sensitivity of peripheral tissues. However, these medications have been shown to cause liver toxicity. Therefore, it is recommended to check liver enzymes before initiating therapy and every other month for the first year of therapy.

EKG (choice B) is not indicated as she has no cardiac complaints, no cardiac history, and is normotensive.

Given her complaints of fatigue and weight loss, a thyroid disorder was a possibility in your workup. However, given her normal TSH, further thyroid studies (choice C) are not necessary at this time.

1-hour glucose tolerance test(choice D), is no longer used as a method for diagnosing diabetes except as a screening test during pregnancy. The patient’s fasting glucose of 206, along with her classic symptoms are enough to make the diagnosis.

It is important to screen all diabetic patients for renal disease. Though screening for microalbuminuria is indicated, it is best performed by a spot urine microalbumin/creatinine ratio, instead of a 24 hour urine test(choice E).

The correct answer is D. This patient is presenting with a classic syndrome of inappropriate antidiuretic hormone secretion (SIADH). He has hyponatremia with elevated urine osmolality in the presence of decreased serum osmolality. The clinical symptoms are often vague like his, until more serious seizures or coma present. One of the most common causes of SIADH is small cell cancer of the lung, which he most likely has. The mainstay of treatment is with fluid restriction once the serum sodium level is greater than 125 mEq/L. If the patient’s initial sodium is less than 125 mEq/L, then treatment with 0.9% normal saline or possibly even more hypertonic solutions (choice A) may be necessary. It is important not to correct the sodium level too quickly or a deadly syndrome known as central pontine myelinolysis may result. The actual appropriate rate is controversial. However, some recommend a rate of less than 0.5 mmol/L/hr. A CT scan of the chest will also be helpful to both the surgeon and oncologist.

Demeclocycline is a medication that actually has nephrogenic diabetes insipidus (the opposite of SIADH) as one of its side effects by blocking the action of antidiuretic hormone. This medication is often adjunctive in the treatment of SIADH. However, you would not simply want to follow up with the patient in 2 weeks (choice B). They need much more vigilant care, as further hyponatremia can result in severe neurologic sequellae.

Similarly, a lung biopsy (choice C) and a referral to an oncologist (choice E) will certainly be eventually required in this patient. However, treating the hyponatremia is of prime importance.

The correct answer is B. This patient has blood sugars which are poorly controlled in the morning and at 9 p.m. Fasting sugars are a reflection of night time NPH doses while late morning sugars are a reflection of a.m. regular doses. Evening sugars reflect dinner time regular insulin. The approximate onset of action, peak effect, and duration of action of NPH insulin and regular insulin are shown below:

Decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH insulin (choice A) would increase 11 a.m. sugars and decrease 4 p.m. sugars.

Increasing NPH insulin and regular insulin doses prior to breakfast (choice C) would be reflected in 11 a.m. and 4 p.m. sugars respectively.

Increasing pre-breakfast regular insulin and increasing pre-dinner regular insulin (choice D) would be reflected in 11 a.m. and 9 p.m. sugars respectively.

Increasing pre-dinner regular insulin dose only (choice E) would reduce 9 p.m. sugars only.

This question might seem confusing, but when confronted with a question that requires that you adjust a patient’s insulin regimen it is helpful to answer the question without looking at any answer choices. You could then simply match your answer with the answer choices. Again, remember that a.m. regular insulin will control glucose levels after breakfast. NPH insulin given in the morning will peak around lunch time and will be reflected in post-lunch sugars. Pre-dinner regular insulin will obviously help you with night time or post-dinner sugars and night time NPH will help you control overnight sugars. If you remember this, this question becomes much less overwhelming.

The correct answer is B. Hyperkalemia with electrocardiographic changes (peaked T waves) requires immediate medical treatment to prevent the onset of hyperkalemia-induced dysrhythmias. Administration of insulin intravenously causes serum potassium to move intracellularly, acutely reducing serum potassium. Glucose is co-administered to prevent insulin-induced hypoglycemia.

Oral glucose (choice A) is of no utility in the treatment of hyperglycemia. Even when insulin is used for the treatment of hyperkalemia, glucose should be co-administered intravenously.

Oral furosemide (choice C) is an appropriate choice for the long-term treatment of hyperkalemia, i.e., once the acute hyperkalemia has been treated. Interventions such as insulin and glucose simply cause the potassium to shift intracellularly. Its excretion can then be promoted by administration of diuretic agents such as furosemide.

Ringers lactate (choice D) should be avoided with hyperkalemic patients since it contains potassium as a constituent (4 mEq/L).

Sodium chloride (choice E) is not useful in the management of hyperkalemia.

The correct answer is B. All drugs (substances in general) are eliminated from the body by means of either renal or hepatic clearance or both. This is one of the most important concepts known by physicians. Almost every patient that presents to inpatient medical services today has some impairment of one or both of these mechanisms. This must be kept in mind when prescribing any drug. In the case of this patient, renal antibiotic dosing schedules for variable renal function are available to every student and house officer and should be consulted regularly. This patient has a creatinine of 2.1 mg/dL, reflecting abnormal renal function.

Antimicrobial dosing must be adjusted due to decreased liver function (choice A), although true as a general rule, is not particularly relevant to diabetics since their disease has no impact on liver function. We have no specific evidence that this patient has impaired hepatic function.

Diabetics have the same epidemiology of pulmonary infections as non-diabetics (choice C) is incorrect as diabetics are more likely to suffer from Staphylococcus aureus and fungal pneumonia.

It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics (choice D) is incorrect. Although certain patient populations tend to have anatomical variation in the location of their pneumonia, the common relationship between all of them is that they suffer from some sort of aspiration. Examples include intubated patients on mechanical ventilation and alcoholics. Diabetics are not included in this group.

Oral antibiotics are not efficacious for treating pneumonia in diabetics (choice E) is false. Oral antibiotic efficacy is determined by the causative organism and location of the infection. Some specific dysfunctions such as gastric achlorhydria or bowel obstruction may interfere with oral efficacy, but not simply the presence of diabetes. Being a diabetic may make one prone to more malignant infections. There is no data that initial treatment of community acquired pneumonia in diabetics should be any different when compared to non-diabetics.

The correct answer is E. Metformin acts predominately to decrease hepatic glucose production in the liver. It is an excellent choice for obese patients with diabetes because it promotes modest weight loss by actually decreasing the amount of insulin necessary because of decreased glucose produced by the liver. It is an appropriate drug for monotherapy or combination therapy of diabetes. It should not be used in patients with renal failure or those patients who are 80 years of older (creatinine clearance decreases with age) because or the risk of lactic acidosis. When metformin is used correctly, complications are uncommon. Because the amount of insulin secreted is not increased, it does not cause hypoglycemia.

Acarbose (choice A) is an alphaglucosidase inhibitor. It works by decreasing the rate of glucose entry into the blood stream, thereby preventing some of the post prandial hyperglycemia. Acarbose has been shown to give a slight decrease in hemoglobin A1C concentrations. In clinical practice, these drugs are poorly tolerated because of gastrointestinal side effects such as diarrhea, bloating, and gas.

Chlorpropamide (choice B) is a first-generation sulfonylurea. It works (as do all drugs in the sulfonylurea class) by binding to a receptor on the beta cells of the pancreas and stimulating insulin secretion. This class of drugs can be used as first-line treatment or can be used in combination with other medications. Chlorpropamide is rarely used today because of its propensity to cause more hypoglycemia than newer drugs in the class.

Patients on multiple medications who continue to have poor glycemic control can be tried on a bedtime dose of NPH insulin. (choice C). If this is not effective, then twice a day injections with 70/30 should be added.

Insulin 70/30 (choice D) is typically used only if poor control is achieved with oral agents. Obviously, most patients would prefer to take medication by mouth rather than injecting themselves with insulin. An exception to this would be a type II diabetic who presents with symptoms of hyperglycemia such as weight loss, polyuria or polydipsia. These patients can be started on insulin as initial therapy.

Above imformation from Clinical Geriatrics “Improving Disease Management with New Treatments for Type 2 Diabetes Mellitus” Volume 8, number 7, June 2000.

The correct answer is B. This patient most likely has a vitamin A (retinoic acid) deficiency, which is characterized by night blindness and dry, hyperkeratotic skin. It can progress to conjunctival dryness, corneal ulceration, and necrosis. It occurs in patients with malabsorption or proteinuria, liver disease, alcoholics, and those receiving total parenteral nutrition (TPN).

Niacin (choice A) deficiency, which is often called pellagra, is characterized by diarrhea, dementia, and dermatitis. It occurs in individuals with a high intake of maize (corn). It is not associated with night blindness.

Vitamin B1 (thiamine) deficiency (choice C), which is often called beri-beri, is characterized by high output heart failure and central nervous system disturbances (Wernicke-Korsakoff syndrome). Wernicke-Korsakoff syndrome occurs in alcoholics and is associated with nystagmus, ataxia, confabulation, and retrograde amnesia. It is not associated with night blindness.

A deficiency of vitamin B₁₂ (choice D) is associated with megaloblastic anemia and peripheral neuropathy. It is not associated with night blindness. It occurs in individuals with pernicious anemia, postgastrectomy, and those with intestinal organisms or ileal abnormalities.

A deficiency of vitamin C (choice E), which is often called scurvy, is characterized by easy bruising, perifollicular hemorrhages, purpura, poor wound healing, bone lesions, and emotional changes. It is not commonly associated with night blindness. It occurs in individuals with diets devoid of citrus fruits and vegetables.

The correct answer is D. This patient has diabetic ketoacidosis (DKA) and has most likely developed cerebral edema, which should be treated with mannitol and dexamethasone. If this is not effective, hyperventilation should be induced. DKA is characterized by hyperglycemia, osmotic diuresis, metabolic acidosis, and elevated ketones. The typical clinical presentation is abdominal pain, nausea, vomiting, polyuria, and lethargy. It is usually precipitated by an infection, stress, a cessation of insulin intake, or surgery. The initial treatment includes insulin and isotonic saline or Ringer’s lactate. As glucose and potassium levels begin to fall, potassium and glucose solutions must be given. Bicarbonate is given to patients with severe acidosis. If the glucose level is corrected too rapidly and glucose is not added to the intravenous fluids as the levels fall below 300 mg/dL, cerebral edema may develop. Clinically, cerebral edema manifests as acute altered mental status, vomiting, and a headache. A CT scan is used to make the diagnosis.

Adding more potassium to the intravenous solution (choice A) would not be the appropriate management of cerebral edema, which requires mannitol. This patient’s acute complication is inconsistent with hypokalemia, which is typically associated with cardiac arrhythmias.

Adding phosphate to the intravenous solution (choice B) is an important part of the treatment of DKA. However, this patient is most likely suffering from cerebral edema, which is a life-threatening condition that requires rapid treatment with mannitol, not phosphate. Patients with hypophosphatemia typically complain of muscle weakness.

Sodium bicarbonate (choice C) is typically used in severely acidotic patients with hypotension. It is not used to treat cerebral edema.

Increasing the dose of insulin (choice E) is incorrect because this patient has cerebral edema, which is most likely caused by the rapid fall of glucose, and so you would not want the glucose levels lowered even more rapidly.

The correct answer is D. This patient has hypernatremia as a consequence of insensible free water losses. He needs free water repletion with one half the free water deficit being given in the first 12 hours and the remaining half over the next 24 hours. The serum sodium should fall by no more than 0.5mEq/L/hour (12 mEq/day).

Intravenous half-normal saline repletion (choice A) will worsen the condition. Although there is more free water in this preparation, the added sodium will likely worsen this patient’s condition.

There is no role for intravenous lactated ringers repletion (choice B) in correcting hypernatremia since it has a similar sodium content as normal saline.

Intravenous normal saline repletion (choice C) will aggravate the condition by providing only some free water and the remainder sodium. This is used to replete some forms of hyponatremia.

Oral thiazide diuretics (choice E) are often a treatment for hypernatremia when salt sodium excess is the primary problem. This can occur with hypertonic dialysis solutions.

The correct answer is A. This patient has Graves disease or thyroid ophthalmopathy. Cigarette smoking has been linked to an increased severity of thyroid ophthalmopathy. The exact reason for this is not known, but patients who smoke should be informed of this association as further encouragement to quit smoking.

The diplopia in Graves disease is from infiltration of the extraocular muscles causing restriction of extraocular motility and not from cranial nerve palsies (choice B).

The degrees of exophthalmos and thyroid function run different clinical courses. Treatment of thyroid dysfunction is certainly indicated, but this will not affect the patient’s ocular findings (choice C). Furthermore, the ocular findings of Graves disease may precede the onset of dysthyroidism or become apparent many months after the thyroid function has been treated.

Ocular dryness, redness, irritation, and diplopia are all very common signs and symptoms of Graves disease; however, the clinician should be aware that compression of the optic nerve can occur. If unrecognized and not treated, then an optic neuropathy can cause visual loss (choice D). All patients with thyroid ophthalmopathy should be referred to an ophthalmologist for evaluation.

Unilateral exophthalmos is not uncommon (choice E) and should not eliminate the diagnosis of Graves disease. In fact, the most common cause of unilateral exophthalmos is Graves disease.

The correct answer is E. This patient is dehydrated with postural hypotension and circulatory failure. These findings are seen with adrenal insufficiency. Biochemically, the patient has a low sodium concentration, high normal potassium concentration, and an increased creatinine concentration. All findings are consistent with loss of mineralocorticoid action. These are the features of primary adrenal failure. This patient requires immediate management of adrenal crisis with adequate hydration with saline and administration with intravenous steroid. Relatively minor urinary or respiratory tract infections can precipitate adrenal crisis and should be appropriately treated.

The patient’s hypoglycemia does not require specific management and will correct itself without dextrose (choice A).

Dextrose is not indicated as stated above and norepinephrine (choice B) is not indicated before adequate aggressive hydration for the correction of an adrenal crisis.

Dextrose, saline, and levothyroxine (choice C) are incorrect, because dextrose and levothyroxine are not indicated. The patient’s hypoglycemia should correct itself, and there is no indication for dextrose or levothyroxine in this patient.

Although saline and antibiotics are indicated in this patient, norepinephrine (choice D) is not indicated in the initial management of this patient.

The correct answer is C. This patient most likely has congenital hypothyroidism. Newborns born in hospitals in the United States are usually screened for hypothyroidism. The clinical manifestations can be avoided with early diagnosis and treatment. The features include prolonged jaundice, poor feeding, hoarse cry, constipation, short stature, protruding tongue, dry skin, myxedema, umbilical hernia, and developmental abnormalities. The diagnosis is established by finding decreased levels of thyroxine and triiodothyronine and an increased level of thyroid-stimulating hormone. The treatment is thyroid hormone replacement. The most common causes of congenital hypothyroidism are structural lesions of the thyroid or pituitary, hormone synthesis defects, and maternal intake of radioiodine during pregnancy.

The measurement of galactose-1-phosphate-uridyl transferase levels (choice A) is used to diagnose galactosemia, which presents with jaundice, hepatosplenomegaly, seizures, hypoglycemia, cataracts, and vomiting following the consumption of galactose-containing foods (milk). Dietary restriction of galactose-containing foods prevents these symptoms.

The measurement of phenylalanine hydroxylase levels (choice B) is used to diagnose phenylketonuria, an autosomal recessive disorder which is characterized by light hair and skin, a “mousy” odor, seizures, vomiting, dermatitis, and growth retardation. The early diagnosis and the dietary restriction of phenylalanine can prevent these symptoms.

Reassurance (choice D) is inappropriate because even though constipation is very common in formula-fed infants, this girl’s physical examination reveals many abnormalities that are consistent with hypothyroidism, which is also associated with constipation.

A rectal biopsy (choice E) is used to establish the diagnosis of Hirschsprung disease, which is due to a lack of ganglion cells in the distal colon. It is very unlikely that this infant has this relatively rar,e (1 in 5,000) disease that is often suspected if a newborn does not have stool in the first 24 hours of life. Infants with this disease often have a distended abdomen, and a rectum that is devoid of stool. It is more likely that this infant with no previous medical care, constipation, and other physical abnormalities, has hypothyroidism.

Analysis of sex chromosomes (choice F) would diagnose Turner syndrome, which is usually characterized by a 45, X karyotype. Affected infant girls usually have edematous hands and feet and congenital heart defects. Childhood manifestations include short stature and primary amenorrhea.

The correct answer is A. This patient most likely has a pheochromocytoma. The classic triad of headache, palpitations, and diaphoresis should suggest this diagnosis. Patients are frequently hypertensive but sometimes the hypertension is paroxysmal and a normal blood pressure is found on exam. Prior to surgery this patient must be started on an alpha-blocker (phenoxybenzamine) to avoid intraoperative hypertensive crisis. Laparoscopic adrenalectomy is the treatment of choice for a pheochromocytoma.

Treatment with a beta blocker (choice B) is initiated only after a patient is started on an alpha blocker. Unopposed alpha stimulation can worsen hypertension in patients with a pheochromocytoma.

Laparoscopic adrenalectomy (choice C) is the treatment of choice for pheochromocytoma but medical stabilization is essential prior to surgery. Pheochromocytoma is not an indication for emergent surgery.

Serial CT scans (choice D) are important in the management of non-functioning adrenal masses (incidentaloma). When an adrenal mass is discovered incidentally and it is < 6cm repeat imaging is indicated to ensure that the mass is not quickly growing. A rapidly growing adrenal mass is suggestive of malignancy.

Fine needle aspiration (choice E) is an important tool in the workup of an adrenal mass. However, prior to aspirating any adrenal mass, pheochromocytoma must be ruled out to avoid precipitation of hypertensive crisis. Fine needle aspiration is not indicated in the management of pheochromocytoma since it can exacerbate a hypertensive crisis.

The correct answer is E. This patient’s symptoms of anxiety, bilateral proptosis, and a decreased thyroid stimulating hormone (TSH) are consistent with hyperthyroidism with thyroid ophthalmopathy. A thorough funduscopic exam will reveal papilledema. An uncommon complication of thyroid ophthalmopathy (5% of cases) is optic neuropathy from edema of the extraocular muscles with secondary compression of the optic nerve.

Anxiolytic therapy with buspirone (choice A) may be necessary, but treatment of the underlying hyperthyroidism is the primary clinical concern. The next most appropriate step is to perform a thorough funduscopic examination to evaluate for papilledema.

Anticoagulation (choice B) is not necessary. This patient is suffering from optic nerve compression secondary to extraocular muscle edema, not a stroke.

Anxiolytic therapy with diazepam (choice C) may be necessary, but treatment of the underlying hyperthyroidism is the primary clinical concern.

Vision loss is a rare complication of a seizure which could be evaluated by EEG (choice D). Seizure as a cause of vision loss is an unlikely possibility given that this patient has anxiety, bilateral proptosis, and an elevated thyroid stimulating hormone (TSH). These findings are all consistent with hyperthyroidism and secondary thyroid ophthalmopathy.

Anticoagulation with heparin (choice F) is not necessary. This patient is suffering from optic nerve compression secondary to extraocular muscle edema, not a stroke.

The correct answer is B. When looking at arterial blood gases, examine the pH to identify the acid-base disturbance and then determine whether the acid-base disturbance is respiratory (change in CO₂) or metabolic. The relationship between PaCO₂ and pH determines whether the condition is acute or chronic. Chronic conditions have a pH closer to 7.4 than would be predicted based upon PCO₂ because of compensation. This patient has diabetic ketoacidosis. This condition occurs when some event “pushes” the patient over the edge and they are unable to regulate glucose balance. Typical events include infection or stress. For this man, his primary problem is a metabolic acidosis that will cause him to hyperventilate to compensate for. His oxygenation will be essentially normal since he has no pulmonary pathology: PaCO₂ 14 mm Hg, pH 7.22, and PaO₂ 90 mm Hg.

A PaCO₂ of 14 mm Hg, pH of 7.12, and PaO₂ of 60 mm Hg (choice A) reflects a profound metabolic acidosis with hypoxemia. This is not DKA but perhaps a condition such as sepsis or cyanide poisoning.

A PaCO₂ of 14 mm Hg, pH 7.38, and PaO₂ 90mm Hg (choice C) represents a chronic acidosis. The pH is mildly acidic with a very low PaCO₂. For this PaCO₂, the patient should be alkalotic, but since he is not, it must have increased the pH from a very low level to near normal. This is the hallmark of a compensated metabolic acidosis. This can be seen with conditions such as Type I and II renal tubular acidosis.

A PaCO₂ of 35 mmHg, pH 7.36, and PaO₂ of 90 mm Hg (choice D) is a compensated metabolic acidosis. The PaCO₂ is nearly normal which suggests the acidosis is mild. Such mild acidosis can occur with specific renal tubular disorders or with chronic diarrhea.

A PaCO₂ of 68 mmHg, pH 6.80, and PaO₂ of 60 mm Hg (choice E) represents a combined metabolic/respiratory acidosis. The patient has a severe acidosis (pH), the expected PaCO₂ should be low to compensate. Instead, it is high. The patient also has hypoxemia. This is typical of severe respiratory failure. Hypoxia causes a metabolic acidosis and the pulmonary system cannot compensate.

The correct answer is C. Ordering a thyroid function test is correct, because this patient demonstrates not only physiological hyperthyroid changes (i.e. increased heart rate), but also cutaneous findings classic for Graves disease. Skin changes are distinctive in hyperthyroidism. The cutaneous surface is warm, moist, and smooth textured. Palmar erythema or facial flushing may be seen. The hair is thin and has a downy texture and nonscarring alopecia may be observed. Graves disease has a female to male ratio of 7:1. Thyroid acropachy is characterized by digital clubbing and diaphyseal proliferation of the periosteum in acral and distal long bones (tibia, fibula, ulna, and radius). Pretibial myxedema consists of bilateral localized, cutaneous accumulations of glycosaminoglycans and occurs in 4% of patients who have or have had Graves disease. Improvement in plaques of pretibial myxedema have resulted from intralesional injections of triamcinolone acetonide and with clobetasol solution under Duoderm occlusion, applied once weekly for 4-6 weeks. Systemic steroids are of no benefit.

Checking testosterone level (choice A) is incorrect, because an elevated testosterone level would only account for hair thinning, but not her other physiologic and cutaneous changes.

Giving her aluminum chloride (choice B) is incorrect, because this solution will only alleviate sweaty palms and soles for this patient, but does not help to diagnose and treat the underlying issue.

Referring her to ophthalmology (choice D) is incorrect, because eventually this patient may need to see an ophthalmologist for severe exophthalmos, but diagnosing Graves disease is the more appropriate first step for this patient.

Despite her family history of psychiatric illnesses, referral to psychiatry (choice E) is incorrect, because this patient’s manic appearance is most likely secondary to thyroid hormone imbalance.

The correct answer is D. Abnormal liver function is one of the main side effects associated with HMG-CoA reductase inhibitors, which are one of the most common classes of drugs prescribed for elevated cholesterol. While this side effect is relatively uncommon (1-2%), it can be very serious. It is important to monitor cholesterol and liver function tests at 6 weeks and 12 weeks after the initiation of therapy or when the dosage is increased, and then every 4-6 months.

It is important to order liver function tests and to remind her to call you if she develops any side effects from the medication, before you let her go pick up her children (choice A).

There is no apparent reason to measure uric acid levels (choice B) in this patient at this time. Niacin, not HMG CoA reductase inhibitors, is associated with elevated uric acid levels. Even though this patient has a history of gout, she does not have symptoms now and she is specifically at the office for a follow-up examination after starting lovastatin.

Myositis is one of the other side effects of HMG CoA reductase inhibitors, but this too is relatively uncommon. Myositis occurs more frequently when combined with other cholesterol lowering agents. Discontinuation of the medication is important if these symptoms occur because rhabdomyolysis with renal failure and death can occur. The routine measurement of creatine kinase levels (choice C) is not recommended. It is usually done when patients complain of muscle aches and cramps.

While it is important to remind her to call you if she develops any side effects from the medication (choice E), such as muscle aches, you first need to order liver function tests.

The correct answer is B. This patient has gout. Pain in the MTP joint of his first toe is a classic symptom and is known as podagra. All of the comorbid medical conditions associated with gout are listed in the case and include diabetes, hypertension, coronary artery disease, hyperlipidemia, obesity, and chronic renal disease. Excessive dietary purine intake along with alcohol may also contribute. Patients with gout should be encouraged to modify their diets to minimize secondary causes of hyperuricemia.

Allopurinol (choice A) is a xanthine oxidase inhibitor which is an effective therapy for hyperuricemia. Allopurinol has no role in the treatment of acute gout since it may cause the mobilization of tophi, thereby causing increased pain. It is useful to keep the uric acid level within normal limits. NSAIDS are the treatment of choice for acute gout. Colchicine and steroids are other alternatives.

Asymptomatic hyperuricemia (choice C) without evidence of gout is not typically treated. Most physicians would wait until the first attack of gout before initiating allopurinol treatment. Of note, uric acid levels are not helpful in the diagnosis of acute gout because they can be normal in some patients.

Most patients have recurrences of gout in their lifetime. The majority of patients even have recurrences within the first year. Therefore a single attack, (choice D), is incorrect.

Overproduction of uric acid (choice E) is responsible for about 10% of the patients with gout. This can be a primary process secondary to defects in the purine enzyme pathways or can be secondary from alcohol, heme malignancy, or chemotherapy. 90% of the patients with gout are under-excreters, which means they excrete less than 700 mg of uric acid per day.

The correct answer is B. This patient has subclinical hypothyroidism (elevated TSH with a normal free T4). Treatment is recommended if the patient has symptoms. Ordering further studies such as thyroid function test or thyroperoxidase antibody will help support your diagnosis. Clues to the diagnosis of hypothyroidism include weight gain, difficulty concentrating, hoarse voice, dry skin, thinning of the eye brows laterally, goiter, etc. Treatment with levothyroxine should be initiated in our patient since she has many of the classic symptoms of hypothyroidism. It is likely that this patient, if untreated, would develop clinical hypothyroidism in the future, which would require treatment. In a young, otherwise healthy person, therapeutic doses of levothyroxine can be started initially. In older patients or patients with heart disease low-dose levothyroxine should be started with a slow titration to therapeutic doses to avoid cardiac complications.

Depression is often a part of hypothyroidism and the two disorders can often mimic each other. Prior to starting a patient on an SSRI (choice A), reversible causes of depression (such as hypothyroidism) need to be excluded. Since depression is so prevalent, it is reasonable to reevaluate this patient for depression after she is euthyroid.

Therapy with a statin drug (choice C) is not appropriate at this time. This patient does have an elevated LDL and total cholesterol but two things need to be remembered: first, hypothyroidism can cause high cholesterol so it is necessary to recheck the patient’s cholesterol when euthyroid. Second, this patient needs a trial of exercise and diet prior to being placed on a lipid-lowering drug.

Propylthiouracil (choice D) is a therapy for hyperthyroidism, not hypothyroidism. It acts by inhibiting the iodination of thyroid hormone and acts to block the peripheral conversion of T3 to T4.

This patient has a macrocytic anemia, which is often associated with B12 and folate deficiency (choice E). A less common cause of macrocytic anemia is hypothyroidism. This patient’s anemia may resolve once treatment with levothyroxine is initiated.

The correct answer is C. This patient has Grave’s disease, which is a common cause of hyperthyroidism, and it important to discuss the advantages and disadvantages of the treatment options. The major disadvantage of radioiodine therapy is that 40-70% of patients will develop hypothyroidism and require thyroid hormone replacement within 10 years. Grave’s disease is characterized by diffuse goiter, dermopathy, and ophthalmopathy. The clinical manifestations are that of hyperthyroidism and include palpitations, tremors, weakness, weight loss despite an increased appetite, frequent bowel movements, heat intolerance, and oligomenorrhea or amenorrhea. Proptosis, lid lag, and stare are often present. The dermopathy, which is called pretibial myxedema, is usually characterized by waxy, infiltrated plaques over the dorsum of the legs and a peau d’orange appearance. Laboratory studies show low or undetectable levels of TSH, and elevated levels of T4, T3, and the RAIU and RT3U. Radioactive iodine therapy is a good choice for treating hyperthyroidism in adult patients, patients with previous thyroid surgery, and those who cannot undergo surgery. Long-term antithyroid therapy with methimazole or propylthiouracil is usually used in children.

It would be incorrect to inform her that continuous or repeated doses of radioiodine is usually necessary (choice A). Continuous or repeated therapy with antithyroid drugs (methimazole or propylthiouracil) is often necessary.

It would be incorrect to inform her that hepatitis, arthralgias, agranulocytosis, and a rash are common side effects of radioiodine therapy (choice B) because these are associated with antithyroid drugs, not radioiodine therapy.

It would be incorrect to inform her that radioiodine therapy is the treatment of choice if she is currently pregnant (choice D) because radioiodine therapy should never be given to pregnant women. Antithyroid drugs are usually used during pregnancy.

It would be incorrect to inform her that there is plenty of evidence that the dose of radioiodine that she will receive has leukemogenic effects (choice E) because this is not true. There is no evidence to support this statement (in adults).

The correct answer is A. This patient is on chronic steroids for her rheumatoid arthritis. She has a urinalysis consistent with a urinary tract infection and given her flank tenderness and elevated WBC, probably has pyelonephritis. However, given her chronic steroid use, this patient is relatively adrenal insufficient and can’t mount a stress response. She therefore has orthostatic hypotension with eosinophilia and a low glucose. Additionally, her serum sodium is low and her potassium is high, another useful clue to her mineralocorticoid deficiency. If adrenal insufficiency is suspected, then stress dose IV steroids would be the initial management

An endocrinology consult (choice B) would be too time consuming and would just delay life saving treatment.

Checking serum cortisol levels (choice C) would be helpful to solidify the diagnosis of adrenal insufficiency. However, IV steroids need not be delayed given this patient’s history and classic lab findings. Furthermore, this question asks for the next step in management, not diagnosis.

This patient doesn’t require a blood transfusion (choice D) for her anemia. It is most likely her steroid deficiency that is contributing to her hypotension, not her chronic anemia.

This patient will require IV antibiotics (choice E) for the pyelonephritis, but the first initial step for management would include stress-dose steroids.

The correct answer is E. This patient most likely has subacute combined degeneration of the spinal cord, which is a condition caused by vitamin B12 deficiency. It is most often caused by pernicious anemia, but it may be acquired in patients with strict vegetarian diets or small bowel disease. The clinical manifestations include weakness, paraesthesias, loss of vibratory sensation, increased deep tendon reflexes, and extensor plantar responses. The gait is ataxic. Mental changes may also occur. The diagnosis is usually established by measuring serum vitamin B12 levels. The treatment is vitamin B12 replacement.

Guillain-Barre syndrome (choice A) is an acquired demyelinating neuropathy that usually follows a viral respiratory infection or immunizations. It is characterized by ascending weakness. Sensation is intact. A main diagnostic clue is absent deep tendon reflexes.

Lambert-Eaton syndrome (choice B) is a neuromuscular disorder that causes proximal muscle weakness, ptosis, and diplopia. Deep tendon reflexes are depressed or absent. Repetitive nerve stimulation shows increased responses. Small-cell carcinoma of the lung has been associated with this disorder.

Myasthenia gravis (choice C) is a neuromuscular disorder due to autoantibodies to the acetylcholine receptors. It is characterized by weakness and easy muscle fatigability. The extraocular and eyelid muscles are affected, leading to diplopia and ptosis. Deep tendon reflexes are preserved.

Polymyositis (choice D) is a skeletal muscle disorder that is characterized by progressive proximal muscle weakness. Patients often complain of difficulty climbing stairs and brushing hair. Ocular muscles are generally not affected. Creatine kinase is elevated. Muscle biopsy and electromyography confirm the diagnosis.

The correct answer is B. The initial work-up for weight gain is a detailed history, including medication and drug use and recent smoking cessation, and a biochemical profile. A biochemical profile may indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes will most likely lead to an elevated glucose, while Cushing is sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis, hyperglycemia, and hypercholesterolemia. An individual with an “apple-shaped” body typically has a large abdomen and chest and thin legs. A “pear-shaped” body typically refers to a thin torso with larger hips, buttocks, and legs. This is included in the vignette to show that the patient’s “obese abdomen” is consistent with her family’s body type and is not necessarily associated with Cushings or any other conditions.

Determining thyroid stimulating hormone levels (choice A) is appropriate in the evaluation of weight gain if there is a negative drug history, no recent smoking cessation, and a normal biochemical profile. Since hypothyroidism is part of the differential diagnosis for weight gain, you should consider it early in the work-up, but a biochemical profile should be performed first.

A dexamethasone suppression test (choice C) is part of the initial evaluation of Cushing syndrome. You should first order a biochemical profile to determine if this diagnosis is more likely than diabetes mellitus.

Referring her to a nutritionist (choice D) is inappropriate at this time. The case says that the patient has had weight gain with no change in appetite or eating habits. She requires evaluation for a medical condition, such as Cushing syndrome, diabetes mellitus, thyroid disease, (even though this is usually associated with a poor appetite), and fluid overload.

A CT scan of the abdomen (choice E) may be used to visualize an adrenal mass leading to Cushing syndrome and weight gain. It may be ordered after a biochemical profile, dexamethasone suppression test, and plasma cortisol. This study is not appropriate at this time.

The correct answer is C. A BUN and creatinine as high as this patient’s reflect a glomerular filtration rate that is below normal, therefore indicating renal insufficiency.

By definition this is renal insufficiency and not normal renal function (choice A).

Although this patient has a HA1C level of 8.3% reflecting a mean blood glucose concentration of greater that 225 mg/dL and therefore poorly controlled diabetes, he does not have severe diabetic renal disease (choice B) based upon the fact that he has only mildly elevated renal indices.

The evaluation of patient as a transplant candidate is a complex process involving medical, psychiatric, and social issues and since we have no information on most of these points, it is not possible to say that this patient is not a candidate for a renal transplant (choice D).

There are five indications for hemodialysis: uremia, hyperkalemia, acidosis, volume, and uremic pericarditis. Since this patient has none of these he does not require hemodialysis (choice E).

The correct answer is E. This patient presented with a thyroid nodule that is suspicious for malignancy. Risk factors for thyroid cancer include radiation therapy to the neck in childhood and family history of thyroid cancer. The fact that the nodule is firm and fixed in place is suggestive of malignancy. Thyroid malignancies are more common in men than in women and more nodules in young patients are malignant than in older patients. Radioactive iodine thyroid scintiscanning is a test which tells us which areas of the thyroid gland are more active and which are less active. Most thyroid malignancies are less active (i.e., cold). The appropriate management of this patient is a fine needle aspiration of the nodule. This can be done safely in experienced hands and has very few complications. It is of great benefit to the physician because it provides tissue to make a definitive diagnosis and guide treatment.

Serial neck exams (choice A) for change in size of the nodule is inappropriate because thyroid cancer found in its early stages is often curable.

Thyroxine therapy (choice B) is important in the management of thyroid cancer and is often used after the thyroid cancer is removed with surgery. Since TSH can stimulate cancers to grow more rapidly it is beneficial to suppress TSH after someone is diagnosed with a thyroid cancer. The dose of Levothyroxine used is the highest dose possible to suppress TSH without causing the patient to be symptomatically hyperthyroid.

Propylthiouracil (choice C) inhibits the oxidation of iodide thereby decreasing the production of thyroid hormone and inhibiting peripheral conversion of T3 to T4 in the blood. It is used in the management of Graves disease as well as other hyperthyroid states. It is not useful in the management of a thyroid nodule.

Thyroid ultrasound (choice D) is sometimes valuable in the work-up of a thyroid nodule. An ultrasound can detect small nodules that even very experienced hands cannot palpate. However these small nodules rarely have malignant potential and a biopsy of these nodules hasn’t been shown to improve mortality. Also, there is no reason to wait 3 months for this evaluation. A FNA should be performed with or without an ultrasound at this visit or as close to this time as possible, not in 3 months.

The correct answer is E. Steroids, especially intraarticular steroids, are very effective when NSAIDs (which are the treatment of choice for gout) are contraindicated. In this patient, chronic renal insufficiency is a relative contraindication to NSAID use. Therefore, intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects.

Allopurinol (choice A) is a xanthine oxidase inhibitor, which is an effective therapy for hyperuricemia. Allopurinol has no role in the treatment of acute gout since it may cause the mobilization of tophi, thereby causing increased pain. It is useful to keep the uric acid level within normal limits and should be started after the acute attack has resolved to prevent recurrences. Do not forget to keep a patient’s comorbidity in mind prior to prescribing treatments. This patient would likely benefit from decreasing his alcohol intake and changing his antihypertensive medication to one that will not increase uric acid levels.

Aspirin (choice B), especially low-dose aspirin, may increase uric acid levels by inhibiting renal excretion of uric acid. Aspirin is therefore not indicated in the treatment of gout.

Colchicine (choice C) is an effective treatment for gout but there are several side effects associated with its use. It is often associated with severe GI side effects. At high doses (especially IV therapy), bone marrow suppression can occur. Liver disease and kidney disease may increase colchicine levels and should be avoided in these patients if possible.

NSAIDs, such as indomethacin, (choice D) are the treatment of choice for most patients with gout. Typically, treatment begins with high dose NSAIDs, which are rapidly tapered. This patient has kidney disease and therefore should not be given high-dose NSAIDs.

The correct choice is C. This patient is presenting with signs and symptoms of gout. Gout is a crystal-induced arthropathy that often presents in older, obese men. Over time, crystal deposits in the joints cause an erosive arthropathy. Colchicine may be used as an alternative to nonsteroidal antiinflammatory medications (NSAID) when there is a history of peptic ulcer disease, excessive bleeding, or intolerance to NSAIDs. Colchicine may also be used as a prophylactic treatment for gout.

Acetaminophen (choice A) is not indicated for an acute gout attack because of its lack of antiinflammatory activity.

Allopurinol (choice B) is used to prevent gouty attacks. It serves no role in an acute attack.

Indomethacin (choice D) is a type of nonsteroidal antiinflammatory medication (NSAID) that is relatively contraindicated given the patient’s history of peptic ulcer disease. However, indomethacin is often considered one of the typical first-line agents for acute gout attacks.

Oral steroids (choice E) are not typically used for an acute gouty attack. Intravenous glucocorticoids are sometimes considered for patients who cannot tolerate oral medications or others who have not responded to other therapies. Intraarticular methyl prednisone or betamethasone is generally reserved for patients with acute gouty monoarticular disease. Steroids are used extensively to treat other inflammatory arthritides like rheumatoid arthritis.

The correct answer is C. This patient is presenting with podagra, the term applied to acute gouty arthritis of the first MTP. This is a common disease associated with elevated uric acid levels in the blood, and typically seen in elderly individuals. One of the most common predisposing factors is the recent institution of a thiazide diuretic. This impairs the renal excretion of uric acid, elevating their blood levels. Many other drugs are associated with hyperuricemia and it can be idiopathic. He should be treated with ibuprofen and his antihypertensive agent should be changed.

The main tenets of treatment are to look for underlying causes, and then symptomatically treat the acute attack. If no predisposing, and alterable factors can be found, it is often helpful to start the patient on allopurinol to prevent future attacks. It is important, however, not to start allopurinol early in an acute attack, particularly, without an anti-inflammatory drug in combination (choice A). This can actually exacerbate the patient’s symptoms.

Ibuprofen 600 mg orally every 8 hours for 4 weeks and starting allopurinol 100 mg once daily as soon as symptoms have resolved, with follow up of uric acid level within 1 month (choice B) is not the most appropriate management for this patient. Even though this is a very typical scenario in the treatment of an acute gouty attack, given the fact that the patient was recently started on hydrocholorothiazide, it is reasonable to try changing this medicine first, rather than adding another medication (allopurinol) to his regimen.

It is true that an acute gouty attack is often self-limited, (choice D). However, it is not appropriate to let the patient suffer pain any longer than he has to. Non-steroidal anti-inflammatory drugs such as ibuprofen will not only help with symptoms, but they will also shorten the duration of the attack.

Probenecid (choice E) is another drug used in the long-term treatment of gout. It actually increases the excretion of uric acid from the kidneys. 24-hour uric acid excretion studies can be performed to identify patients who are so called “underexcretors”. They may be better served by treatment with this medication rather than allopurinol. In either case, it is not the best answer in this question for the reasons described above.

The correct answer is A. The initial evaluation of a patient with fatigue includes a thorough history and physical examination, a complete blood count, and a biochemical profile. These will evaluate the patient for causes of fatigue such as anemia, uremia, diabetes mellitus, adrenal insufficiency, hypokalemia, hyponatremia, and hepatitis. If these tests are negative, thyroid function tests and the evaluation for an infection and an occult malignancy are indicated. If all studies are negative, a nutritional deficiency, depression, a chronic viral infection, or chronic fatigue syndrome should be considered. Even if chronic fatigue syndrome is suspected, routine laboratory studies must be performed to exclude other causes of her symptoms.

A chest x-ray (choice B) is used to evaluate a cardiopulmonary process. Since this patient does not have symptoms that seem directly related to these systems, a chest x-ray is not the most appropriate next step. It may be indicated in the future because fatigue may be associated with cardiopulmonary processes, but a biochemical profile should be ordered next.

Fluoxetine (choice C) is used to treat depression and while it is possible that this patient is depressed, she requires an evaluation with laboratory studies for her fatigue. She does not complain of any other symptoms of depression, such as difficulty sleeping, change in concentration, guilt, worthlessness, and suicidal ideation.

Reassurance and a scheduled follow-up visit in 1 week (choice D) is inappropriate. An evaluation for her fatigue is indicated because a 3-month history of “tiredness” is not normal.

Referring her to a psychiatrist (choice E) may be indicated in the future, but at this time she requires an evaluation for fatigue.

The correct answer is B. The patient likely has septic shock that is characterized by high cardiac output, low systemic resistance, and a relatively normal contractile function (PCWP) and filling pressures (CVP).

CO 5.0 L/min, SVR 800 dynes-sec/cm5, PCWP 12 mm Hg, CVP 4 mm Hg (choice A) is a profile of a normal, healthy person.

CO 2.3 L/min, SVR 1500 dynes-sec/cm5, PCWP 30 mm Hg, CVP 10 mm Hg (choice C) is a profile of cardiogenic shock. This patient has a depressed cardiac output, a markedly elevated PCWP reflecting failure, and an appropriately high peripheral vasoconstrictive response to maintain blood pressure.

CO 3.0 L/min, SVR 1500 dynes-sec/cm5, PCWP 8 mm Hg, CVP 1 mm Hg (choice D) reflects hypovolemic shock with a low output, an appropriately high peripheral resistance but very low filling pressures.

CO 9.5 L/min, SVR 1210 dynes-sec/cm5, PCWP 12 mm Hg, CVP 6 mm Hg (choice E) is representative of a healthy person undergoing vigorous exercise, with augmented cardiac output, normal systemic resistance and filling pressures.

The correct answer is C. All of the answer choices would be important in the initial evaluation of this patient but only serum glucose and electrolytes would yield the diagnosis. This patient likely has diabetic ketoacidosis. Clues to this diagnosis included the “fruity” odor on her breath, history of polyuria and polydipsia, recent weight loss, and dehydration. These laboratory studies will most likely reveal an anion gap acidosis with an elevated glucose.

A CT scan of the abdomen and pelvis (choice A) would help determine if there are and intraabdominal infections (i.e., appendicitis, abscess, etc.) but this is unlikely to be the cause of this patient’s illness. This patient has a benign abdominal exam, which would further support the suspicion that there is not a severe abdominal infection.

Finally, an electrocardiogram (choice B) would be important to evaluate any changes consistent with ischemia, arrhythmia, or electrolyte imbalances but would not give us a diagnosis in this patient. The serum glucose and electrolytes should be ordered immediately because of the physical findings. The EKG can be performed as soon as these are drawn.

A urine drug screen (choice D) is also important in the initial workup of the stuporous patient since drug overdose would certainly be in the differential diagnosis.

A urine pregnancy test (choice E) is an important test to perform in all women of childbearing age with abdominal pain. Her last normal menstrual period ended 3 days ago, so it is unlikely that she is pregnant. Although it would not give us the diagnosis in this case, it should be included in initial screening to rule out an ectopic pregnancy.