Question #1

QID: 72
Topic: Cushing's Syndrome
Subject: Medicine

In Cushing syndrome you find all, except:

a)  Hypotension
b)  Obesity
c)  Striation of skin
d)  Trunk obesity

The correct answer is a)

Explanation:
Cushings syndrome is one of the secondary causes of hypertension. Therefore the
blood pressure would be high. Along with Cushings, the other causes include
Hyperaldosteronism, Aortic coarctation, Pheochromocytoma and Stenosis of renal
artery. Remember the mnemonic C.H.A.P.S. for these 5 causes of secondary
hypertension.

Question #2
QID: 623
Topic: Cushing's Syndrome
Subject: Medicine

What is the diagnostic test of choice to confirm Cushing syndrome?  

a)  CT of abdomen
b)  DST (dexamethasone supression test)
c)  Random serum cortisol
d)  MRI of brain

The correct answer is b)

Explanation:
Cushing's syndrome is a constellation of clinical abnormalities caused by chronic high
blood levels of cortisol or related corticosteroids. Cushing's disease is Cushing's
syndrome that results from excess pituitary production of ACTH, usually secondary to
a pituitary adenoma. Typical symptoms include moon facies and truncal obesity with
thin arms and legs. Diagnosis is by history of receiving corticosteroids or by elevated
serum cortisol.

Diagnosis is confirmed with the dexamethasone test, in which 1, 1.5, or 2 mg of

dexamethasone is administered po at 11 to 12 pm and plasma cortisol is measured at 8
to 9 am the next morning. In most normal patients, this drug suppresses morning
plasma cortisol to ≤ 1.8 μg/mL (≤ 50 nmol/L), whereas patients with Cushing's
syndrome virtually always have a higher level. A more specific but equally sensitive
test is to give dexamethasone 0.5 mg po q 6 h for 2 days (low dose). In general, a
clear failure to suppress levels in response to low-dose dexamethasone establishes the
diagnosis.

Question #3
QID: 981
Topic: Cushing's Syndrome
Subject: Medicine

A 52 year old woman, recently diagnosed with hypertension, presents to her family
physician complaining of hirsutism and acne. Laboratory examination reveals:
cortisol 1500 nmol/L (N: 200 - 660 nmol/L) aldosterone 200 pmol/L (N: 140 - 415
pmol/L) ACTH 4 pmol/L (N: 4 - 22 pmol/L)

Which one of the following is the most likely diagnosis?  

a)  Addison's disease
b)  Cushing's syndrome
c)  Bartter's syndrome
d)  Renal artery stenosis
e)  Conn's syndrome

The correct answer is b)

Explanation:
In Cushing's syndrome, the level of corticosteroids is excessive, usually from
overproduction by the adrenal glands. Corticosteroids alter the amount and
distribution of body fat. Excessive fat develops throughout the torso and may be
particularly noticeable at the top of the back. A person with Cushing's syndrome
usually has a large, round face (moon face). The arms and legs are usually slender in
proportion to the thickened trunk. Muscles lose their bulk, leading to weakness.

High corticosteroid levels over time raise the blood pressure, weaken bones
(osteoporosis), and diminish resistance to infections. The risk of developing kidney
stones and diabetes is increased, and mental disturbances, including depression and
hallucinations, may occur. Women usually have an irregular menstrual cycle.
Children with Cushing's syndrome grow slowly and remain short. In some people, the
adrenal glands also produce large amounts of androgens (testosterone and similar
hormones), leading to increased facial and body hair in women and balding.

When doctors suspect Cushing's syndrome, they measure the level of cortisol, the
main corticosteroid hormone, in the blood. Normally, cortisol levels are high in the
morning and lower late in the day. In people who have Cushing's syndrome, cortisol
levels are very high throughout the day.
Question #4
QID: 96
Topic: Pheochromocytoma
Subject: Medicine

A 65-year-old man presents with a history of paroxysms of sweating, palpitations,

headaches and anxiety. This happens off and on. His blood pressure on exam is
156/95 mmHg. On further history he tells you that one of his relatives had thyroid
cancer.

At this time what tests should be done first?

a)  24 hour urinary catecholamines and metanephrines

b)  Serum VMA
c)  CT of adrenal
d)  CT of head
e)  CMP

The correct answer is a)

Explanation:
This patient needs to be screened for pheocromocytoma. Pheochromocytoma is a
tumor of the adrenal gland which causes very high levels of the catecholamines
(epinephrine and norepinephrine) to be secreted into the bloodstream. This can lead to
many sympathetic nervous system symptoms like elevated blood pressure,
palpitations, anxiety, diaphoresis, headaches, weight loss. These symptoms happen is
spurts or paroxysms.

Diagnoses is made by measuring the level of the catecholamines and their breakdown
products or metabolites which are called metanephrines in a 24 hour urine collection.
Treatment involves medicines to control the blood pressure and surgery to remove the
tumor. (Metanephrine levels are considered the most sensitive and specific test for a
pheochromocytoma, while vanillylmandelic acid is the least specific test and has a
false-positive rate greater than 15%.)

Recall the MEN syndromes. MEN (Multiple endocrine neoplasia) has three types:

MEN I (Wermer syndrome) - tumors of the pancreas, pituitary and parathyroid.

MEN IIa (Sipple syndrome) - medullary thyroid carcinoma, pheochromcytoma and
tumor of the parathyroid.
MEN IIb - Medullary thyroid carcinoma, pheochromocytoma and neuromas.

This patient could have MEN II if you consider his family history.

Question #5
QID: 390
Topic: Pheochromocytoma
Subject: Medicine

A 30-year-old woman complains of episodic headache, sweating, palpitations,

tingling sensation in her hands, shortness of breath, and severe anxiety. After a
thorough work-up, you suspect pheochromocytoma. During an episode of these
symptoms, laboratory findings will probably include which one of the following?  

a)  Decreased plasma free epinephrine

b)  Decreased serum glucose
c)  Increased serum calcium
d)  Decreased serum amylase
e)  Lymphocytosis

The correct answer is c)

Explanation:
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells
typically located in the adrenals. It causes persistent or paroxysmal hypertension. The
classic triad of symptoms in patients with a pheochromocytoma consists of episodic
headache, diaphoresis, and tachycardia. Other common symptoms and signs include
postural hypotension, cold and clammy skin, severe headache, angina, palpitations,
nausea, vomiting, epigastric pain, visual disturbances, dyspnea, paresthesias,
constipation, and a sense of impending doom.

Diagnosis is established by measuring catecholamine products in blood or urine.

Imaging tests, especially CT or MRI, help localize tumors. Treatment involves
removal of the tumor when possible. Drug therapy for control of BP includes a-
blockade, possibly combined with ß-blockade.

Laboratory features of pheochromocytoma include hyperglycemia, hypercalcemia and

erythrocytosis.

Question #6
QID: 918
Topic: Pheochromocytoma
Subject: Medicine

A 40-year-old woman has episodic headaches that last 30 minutes and are associated
with sweating, palpitations, and feelings of apprehension. She has lost 6.8 kg over the
past three months. Physical examination reveals a thin woman with a pulse of 112
beats/minute and a blood pressure of 150/100 mmHg lying and 130/80 mmHg
standing.

Which one of the following is the most likely diagnosis?  

a)  Pheochromocytoma
b)  Hyperaldosteronism
c)  Posterior fossa tumor
d)  Renal artery stenosis
e)  Carcinoid syndrome

The correct answer is a)

Explanation:
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells
typically located in the adrenals. It causes persistent or paroxysmal hypertension.
Diagnosis is by measuring catecholamine products in blood or urine. Imaging tests,
especially CT or MRI, help localize tumors. Treatment involves removal of the tumor
when possible. Drug therapy for control of BP includes alpha-blockade, possibly
combined with beta-blockade. Initiate a beta blocker only after adequate alpha
blockade (usually, 2 days).

Question #7
QID: 935
Topic: Pheochromocytoma
Subject: Medicine

A 40-year-old woman has episodic headaches that last 30 minutes and are associated
with sweating, palpitations, and feelings of apprehension. She has lost 6.8 kg over the
past three months. Physical examination reveals a thin woman with a pulse of 112
beats/minute and a blood pressure of 150/100 mmHg lying and 130/80 mmHg
standing.

Which one of the following is the most helpful diagnostic test?  

a)  CT scan of the brain

b)  Captopril renal nuclear medicine scan
c)  24 hour urinary 5-hydroxyindoleacetic acid (5-HIAA) levels
d)  24 hour urinary aldosterone levels
e)  24 hour urinary vanillylmandelic acid (VMA) and catecholamine levels

The correct answer is e)

Explanation:
A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells
typically located in the adrenals. It causes persistent or paroxysmal hypertension.
Diagnosis is by measuring catecholamine products in blood or urine. Imaging tests,
especially CT or MRI, help localize tumors. Treatment involves removal of the tumor
when possible. Drug therapy for control of BP includes α-blockade, possibly
combined with β-blockade.
Question #8
QID: 112
Topic: DM
Subject: Medicine

Which of the following diabetes drugs is contraindicated in liver and kidney failure?  

a)  Insulin
b)  Metformin
c)  Glyburide
d)  Acarbose

The correct answer is b)

Explanation:
Insulin works by directly pushing glucose from the bloodstream into the cells.
Metformin works by inhibiting hepatic gluconeogenesis. Glyburide is an oral
sulfonyl-urea hypoglycemic drug that increases pancreatic insulin secretion.

Acarbose inhibits enzymes needed to digest carbohydrates. Because the carbohydrates

are not broken down into glucose molecules, less glucose is absorbed into the
bloodstream.

Metformin is contraindicated in people with any condition that could increase the risk
of lactic acidosis, including liver and kidney disorders (creatinine levels over 132
μmol/l).

Question #9
QID: 218
Topic: DM
Subject: Medicine

The drug of choice for an obese diabetic type 2 patient is:  

a)  Acarbose
b)  Metformin
c)  Rosiglitazone
d)  Glyburide

The correct answer is b)

Explanation:
Metformin has been clearly established as the drug of choice in obese patients with
diabetes mellitus. Metformin is as effective as sulphonylureas at reducing HbA1c, and
most importantly has a beneficial effect on overall mortality in obese patients.
Metformin monotherapy is unlikely to be effective in patients who fail to respond to
sulphonylureas, but in patients who are secondary failures to sulphonylureas, the
addition of metformin causes substantial blood glucose lowering. Metformin should
be avoided in patients with renal dysfunction. Otherwise its effects on bodyweight,
serum lipids and its lack of hypoglycemia effect make it an excellent first line agent.

Question #10
QID: 317
Topic: DM
Subject: Medicine

Which of the following is the best test in the long term follow up of a diabetic patient?

a)  HbA1c
b)  C-Peptide
c)  Fasting blood glucose
d)  Random blood glucose
e)  Diary of postprandial blood glucose values

The correct answer is a)

Explanation:
There are two common ways to assess how well diabetes is controlled:
- frequent measurements of blood glucose, and
- measurement of glycohemoglobin (A1c).
Each method has its good and bad points, but combined they give a fairly accurate
picture of the state of glucose control in a diabetic. Most physicians will use both
methods.

Hemoglobin is an iron containing molecule present in red blood cells that is

responsible for transporting oxygen around the body. Glucose can bind irreversibly to
hemoglobin via a process known as glycation. Hemoglobin that has glucose attached
is known as glycated hemoglobin, often abbreviated to HbA1c or simply A1c.

Because red blood cells have life span of 120 days (3 months) measuring the level of
glycated hemoglobin in blood effectively shows the average blood glucose level for
the previous 6-8 weeks. In conjunction with regular blood glucose monitoring diaries,
A1c tests can help in determining if a patient's treatment plan needs altering in any
way to better control blood glucose levels. Studies have shown that glycohemoglobin
values in the "better ranges" correlate with less incidence of diabetic complications
later in life.

> A C-peptide test measures the level of this peptide in the blood. It is generally found
in amounts equal to insulin. A C-peptide test can be done when diabetes has just been
found and it is not clear whether type 1 diabetes or type 2 diabetes is present.
> Self-blood glucose monitoring is a valuable diabetes management tool, which
includes both random (pre- or post-prandial) and fasting blood sugar levels, as
recommended (not postprandial glucose levels only).

Question #11
QID: 797
Topic: DM
Subject: Medicine

Which one of the following is the best indicator of adequate control in a patient with
diabetes mellitus?  

a)  Fasting blood glucose

b)  24-hour glycosuria
c)  Blood glucose 2 hours after meals
d)  Glycosylated hemoglobin (hemoglobin A1C)
e)  Urine free of glucose

The correct answer is d)

Explanation:
In the normal 120-day life span of the red blood cell, glucose molecules join
hemoglobin, forming glycated hemoglobin. In individuals with poorly controlled
diabetes, increases in the quantities of these glycated hemoglobins are noted.

Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated

hemoglobin within the red cell reflects the average level of glucose to which the cell
has been exposed during its life cycle. Measuring glycated hemoglobin assesses the
effectiveness of therapy by monitoring long-term serum glucose regulation.

The International Diabetes Federation recommend HbA1c values below 6.5%, while
the American Diabetes Association recommends that the HbA1c be below 7.0% for
most patients. A high HbA1c represents poor glucose control.

Persistent elevations in blood sugar (and therefore HbA1c) increase the risk for the
long-term vascular complications of diabetes such as coronary disease, heart attack,
stroke, heart failure, kidney failure, blindness, erectile dysfunction, neuropathy (loss
of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of
the stomach).

Question #12
QID: 1103
Topic: DM
Subject: Medicine
A 34-year-old laborer comes to the office because of a 2 kg (5 lb) weight loss and an
increased appetite. He has diabetes mellitus and has been taking insulin in divided
doses. He says that home monitoring of his serum glucose concentration has shown
values from 15 mmol/L to 17.8 mmol/L.
Which of the following is the most appropriate management?

a)  Add metformin
b)  Change to another type of insulin
c)  Increase his caloric intake
d)  Increase his insulin dose
e)  Redistribute his caloric intake

The correct answer is d)

Explanation:
This patient has inadequately treated insulin-dependent diabetes. The goal serum
glucose for therapy is < 6.6 mmol/L. Since there is no indication that the insulin type
is incorrect (hypoglycemia), the patient simply requires an increased dosage of his
current insulin type.
Metformin is an oral antihyperglycemic agent that acts by increasing peripheral
utilization of glucose. The primary purpose of medications such as this is to delay or
avoid the requirement for exogenous insulin. Once a patient is on insulin, these drugs
are of little benefit. Secondarily, most patients with non-insulin dependent diabetes
have relative “insulin resistance” and it is for this reason that glucose utilization drugs
are employed as first line management.
This patient’s symptoms of increased weight loss and appetite are a function of his
poor glucose control, not of inadequate caloric intake. Poorly controlled insulin
dependent diabetics are often thin as they waste muscle to liberate glucose in an
attempt to provide glucose for the body. The defect is with the inability to utilize the
glucose already present so the end result is hyperglycemia and muscle wasting. For
similar reasons, there is no need to alter his caloric distribution.

Question #13
QID: 1554
Topic: DM
Subject: Medicine

A 75 year old white male with well-controlled type 2 diabetes mellitus is scheduled
for an abdominal CT scan with oral and intravenous iodinated contrast.

Which one of the following medications should be withheld 48 hours before and after
the procedure?  

a)  Glyburide (Micronase, DiaBeta)

b)  Glipizide (Glucotrol)
c)  Acarbose (Precose)
d)  Metformin (Glucophage)
e)  Rosiglitazone (Avandia)

The correct answer is d)

Explanation:
Metformin should be withheld before and after radiographic procedures with contrast,
due to its interaction with iodinated contrast materials. This interaction may cause
impaired renal function or lactic acidosis. The other drugs listed do not carry this risk.

Question #14
QID: 2676
Topic: DM
Subject: Medicine

A 81-year-old retired electrical engineer whose wife is a diabetic was experimenting

with his wife’s glucose meter and found that his glucose level was 11 mmol/L. He
used her strips and lancets, and started his own log. After a week, he brings the log to
you. His premeal glucose levels range from about 8.33 mmol/L to 13.9 mmol/L. A
review of his medications shows none that would be likely to increase his glucose
level. A physical examination does not suggest glucose intolerance secondary to a
process other than diabetes. His hemoglobin A1C is 9.0%.

Additional laboratory studies should be performed before prescribing which one of

the following for this patient?  

a)  Insulin NPH (Humulin N)

b)  Metformin (Glucophage)
c)  Glimepiride (Amaryl)
d)  Miglitol (Glyset)

The correct answer is b)

Explanation:
The use of insulin therapy can be as appropriate in the older adult with diabetes as in
younger individuals. In patients with reduced muscle mass, such as the elderly
(especially those older than 80 years of age), using serum creatinine concentration to
estimate the glomeruler filtration rate may be misleading, and creatinine clearance
should be determined. If creatinine clearance is < 70 mL/min, metformin should not
be prescribed. The other two oral antidiabetic agents are safe to use in an elderly
patient without other initial laboratory data.

Question #15
QID: 2731
Topic: DM
Subject: Medicine

Metformin (Glucophage), which is normally used in the management of diabetes

mellitus, has also been shown to have a beneficial effect in:  

a)  Osteoporosis
b)  Hyperthyroidism
c)  Polycycstic ovary syndrome
d)  Right ventricular hypertrophy
e)  Morbid truncal obesity

The correct answer is c)

Explanation:
Recent data suggests that insulin resistance and hyperinsulinemia are important in the
pathogenesis of polycystic ovary syndrome (PCOS). Treatment with drugs that reduce
glucose levels, such as metformin, has been shown to correct many of the metabolic
abnormalities associated with PCOS. Such correction results in resumption of
ovulation, decreased insulin resistance, and improved beta-cell function; it also
produces improvement in cardiovascular risk factors such as dyslipidemia and
impaired fibrinolysis.

Question #16
QID: 2874
Topic: DM
Subject: Medicine

This question is no longer available.

Thank you for your understanding and cooperation.

The correct answer is

Explanation:

Question #17
QID: 2877
Topic: DM
Subject: Medicine

Thiazolidinedione antidiabetic agents include rosiglitazone (Avandia) and

pioglitazone (Actos). Their mechanism of action is:

a)  Decreased insulin resistance 

b)  Decreased carbohydrate absorption in the intestinal tract 
c)  Increased insulin release by the pancreas 
d)  Increased insulin production by the pancreas 
e)  Increased gluconeogenesis

The correct answer is a)

Explanation:
Thiazolidinediones decrease insulin resistance by binding to nuclear peroxisome
proliferators-activated receptors. They decrease gluconeogenesis and have no effect
on insulin release or production by the pancreas, or on intestinal carbohydrate
absorption.

Question #18
QID: 2953
Topic: DM
Subject: Medicine

A 45-year-old male was recently diagnosed with type 2 diabetes mellitus. He presents
to your office today to begin oral antihyperglycemic therapy. Results of a fasting
serum metabolic panel include the following:

                                                                                 Laboratory Findings

                                               Sodium…………………………………………136
mmol/L (N 136-145)
                                               Potassium…………………………………...…3.7
mmol/L (N 3.5-5.1)
                                               Chloride………………………………………..102
mmol/L (N 98-107)
                                               BUN………………………………………….…15
mg/dL (N 7-18)
                                               Creatinine………………………………...……1.7
mg/dL (N 0.6-1.3)
                                               Glucose………………………………………...183
mg/dL

Which one of the following medications would be contraindicated in this patient?  

a)  Glipizide (Glucotrol) 
b)  Acarbose (Precose) 
c)  Metformin (Glucophage) 
d)  Pioglitazone (Actos)

The correct answer is c)

Explanation:
Maintaining good blood glucose control is important for preventing the microvascular
complications of diabetes mellitus. A number of oral antihyperglycemic agents are
available, but each drug class has unique adverse effects that affect their
appropriateness for individual patients. In this case, the patient has evidence of renal
impairment (serum creatinine ≥1.5 mg/dL for men and ≥1.4 mg/dL for women). This
leads to an increased risk of lactic acidosis when a biguanide such as metformin is
used. Other contraindications to biguanide use include hepatic dysfunction,
congestive heart failure, metabolic acidosis, dehydration, and alcoholism. The
sulfonylureas include chlorpropamide (1st generation) and glipizide (2nd generation).
They are associated with weight gain and hypoglycemia. α-Glucosidase inhibitors
(e.g., acarbose) are less effective than other drug classes as monotherapy and can be
associated with gastrointestinal side effects. Thiazolidinediones (e.g., pioglitazone)
are associated with weight gain, edema, and potential liver injury.

Question #19
QID: 2970
Topic: DM
Subject: Medicine

A 48-year-old female presents with a new onset of polyuria and polydypsia. A

random finger-stick blood glucose level is 17.6 mmol/L.

Which one of her medications listed below is most likely to be linked to her new onset
of diabetes?  

a)  Atenolol (Tenormin) 
b)  Trazodone (Desyrel) 
c)  Paroxetine (Paxil) 
d)  Risperidone (Risperidal)

The correct answer is d)

Explanation:
Recent data suggests a link between atypical antipsychotics and diabetes. In
particular, studies have suggested an increased risk of diabetes for patients on
risperidone, quetiapine, clozapine, and olanzapine. This association has been noted
even in patients who do not gain weight on the antipsychotic. The other medications
listed have not been implicated in diabetes.

Some experts recommend checking a fasting glucose level before and soon after
initiating an atypical antipsychotic. In addition, monitoring blood glucose every 3-6
months should be considered, especially in patients with other risk factors for
developing diabetes. Patients with preexisting diabetes may suffer worsened glycemic
control when started on an atypical antipsychotic.
Question #20
QID: 3155
Topic: DM
Subject: Medicine

A contraindication to the use of metformin (Glucophage) in a patient with type 2

diabetes mellitus is:  

a)  Obesity
b)  Insulin resistance
c)  Renal insufficiency
d)  Concurrent use of glyburide (DiaBeta, Micronase)

The correct answer is c)

Explanation:
Metformin decreases glucose production in the liver and increases glucose uptake. It
has no effect on pancreatic insulin secretion. It is useful to help overcome insulin
resistance, and can be used concurrently with a sulfonylurea. Studies have proven its
safety and usefulness in the obese diabetic. It is contraindicated in renal insufficiency,
as increased concentrations of the drug can cause lactic acidosis. Other
contraindications include hepatic disease, a previous history of lactic acidosis, heart
failure treated with drugs, and chronic lung disease.

Question #21
QID: 3254
Topic: DM
Subject: Medicine

Which one of the following is a relative contraindication to prescribing rosiglitazone

(Avandia) and pioglitazone (Actos)?  

a)  Pregnancy
b)  Nonalcoholic fatty liver disease
c)  Lipodystrophy associated with highly active antiretroviral therapy
d)  Anemia

The correct answer is a)

Explanation:
The thiazolidinediones rosiglitazone and pioglitazone are categorized as pregnancy
category C, due to experimental evidence of growth retardation in mid- to late
gestation in animal models. These drugs are approved for the treatment of type 2
diabetes mellitus, and may be beneficial in other conditions associated with insulin
resistance. Liver enzyme elevations are improved in patients with nonalcoholic fatty
liver disease. Although not very effective, the drugs are not contraindicated in patients
with lipodystrophy associated with highly active antiretroviral therapy. The anemia
associated with these drugs is mild and rarely causes clinical consequences.

Question #22
QID: 3289
Topic: DM
Subject: Medicine

A 45-year-old male comes to your office for follow-up of his diabetes mellitus, which
was diagnosed 3 months ago. He wanted to try lifestyle modification, including diet,
exercise, and weight loss, before trying medications. He has lost 3 kg (7 lb), but still is
14 kg (31 lb) overweight. His examination is unremarkable, as is his chemistry
profile. His hemoglobin A1c level is 8.3%.

Which one of the following would be most appropriate at this point?  

a)  Exenatide (Byetta)
b)  Glyburide (Micronase, DiaBeta)
c)  Insulin
d)  Metformin (Glucophage)
e)  Rosiglitazone (Avandia)

The correct answer is d)

Explanation:
The Diabetes Association recommends lifestyle intervention along with metformin as
initial therapy for type 2 diabetes. If the follow-up hemoglobin A 1c is more than 7.0%,
then insulin (most effective), a sulfonylurea (least expensive), or a glitazone (no risk
of hypoglycemia) can be added. The hemoglobin A1c should be checked every 3
months until it is less than 7.0%, and every 6 months thereafter.

Question #23
QID: 3307
Topic: DM
Subject: Medicine

Which one of the following statements regarding blood glucose monitoring in patients
with type 1 diabetes is most correct?  

a)  Blood glucose testing from a fingertip site is preferred

b)  Monitoring blood glucose 5 times per day is too often
c)  A random blood glucose level of 5.6 mmol/L (100 mg/dL) is too high
d)  Continuous blood glucose monitoring can result in higher hemoglobin A1c levels

The correct answer is a)

Explanation:
According to the Diabetes Control and Complications Trial, patients should assess
fingertip blood glucose levels at least 3 times per day, including at bedtime, as well as
before and after exercising and before driving. Although testing from other sites is
usually reliable, it can be inaccurate if performed within 60 minutes of meals or after
exercise. If a patient’s random blood glucose level is less than 5.6 mmol/L (100
mg/dL), a small snack should be eaten. Preprandial results should be 5.0-7.3 mmol/L
(90-130 mg/dL), and postprandial levels should be less than 10.0 mmol/L (180
mg/dL). Continuous blood glucose monitoring has been shown to generally lead to
tighter control and lower hemoglobin A1c levels.

Question #24
QID: 3328
Topic: DM
Subject: Medicine

Which one of the following statements is true regarding the use of exenatide (Byetta)
in the treatment of diabetes?  

a)  It may be used for either type 1 or type 2 diabetes

b)  It may be used as monotherapy for type 2 diabetes, in addition to diet and exercise
c)  Hypoglycemia is a common side effect
d)  It may help with weight reduction
e)   It is safe for use in children and adolescents less than 18 years

The correct answer is d)

Explanation:
Exenatide is indicated in combination with metformin, and/or a sulfonylurea to
improve glycemic control in patients with type 2 diabetes mellitus, when maximally
tolerated doses of these therapies in addition to diet and exercise do not provide
adequate glycaemic control.
In Sep 2012, Health Canada has approved exenatide injection added on to insulin
glargine (with or without metformin) to improve glycemic control.
It rarely causes hypoglycemia, except when used with sulfonylureas. It frequently
causes weight loss. 
There is no experience with Byetta in children and adolescents less than 18 years and
therefore, use of Byetta is not recommended in this age group.
Question #25
QID: 5567
Topic: DM
Subject: Medicine

A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a

nursing home. His blood glucose level, which he rarely checks, is typically over 11.1
mmol/L. His serum creatinine level is 167µmol/L. He also has had several episodes of
heart failure. His current medications include glipizide (Glucotrol), lisinopril (Prinivil,
Zestril), and furosemide (Lasix). Which one of the following would be most
appropriate to add to this patient’s regimen to treat his diabetes mellitus?
a)  The diabetic 1800-calorie/day diet
b)  Metformin (Glucophage)
c)  Pioglitazone (Actos)
d)  Exenatide (Byetta)
e)  Insulin glargine (Lantus)

The correct answer is e)

Explanation:
For geriatric patients in long-term care facilities, the predictable glucose control of
insulin glargine is the best approach to consider initially.

>The current guidelines do not recommend a strict diet for frail diabetic patients in
nursing homes.
>Exenatide is not recommended for the frail elderly because of concerns about weight
loss and nausea.
>Heart failure precludes the use of pioglitazone, and renal failure precludes the use of
metformin.

Question #26
QID: 5596
Topic: DM
Subject: Medicine

Which one of the following most increases insulin sensitivity in an overweight patient
with diabetes mellitus?
a)  Metformin (Glucophage)
b)  Acarbose (Precose)
c)  Glyburide (DiaBeta, Micronase)
d)  NPH insulin

The correct answer is a)

Explanation:
Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This
means lower insulin levels achieve the same level of glycemic control, and may be
one reason that weight changes are less likely to be seen in diabetic patients on
metformin. Acarbose is an alpha-glucosidase inhibitor that delays glucose absorption.

Question #27
QID: 5623
Topic: DM
Subject: Medicine

A 40-year-old female comes to your office for a routine examination. She has been in
good health and has no complaints other than obesity. Her mother is diabetic and the
patient has had a child that weighed 4kg (9 lb) at birth. Her examination is negative
except for her obesity. A fasting glucose level is 7.1 mmol/L, and when repeated 2
days later it is 7.5 mmol/L. Which one of the following would be most appropriate at
this point?
a)  Diagnose type 2 diabetes mellitus and begin diet and exercise therapy
b)  Begin an oral hypoglycemic agent
c)  Order a glucose tolerance test
d)  Tell the patient that she has impaired glucose homeostasis but is not diabetic

The correct answer is a)

Explanation:
The criteria for diagnosing diabetes mellitus include any one of the following:
symptoms of diabetes (polyuria, polydipsia, weight loss) plus a casual glucose level
11.1 mmol/L; a fasting plasma glucose level 7 mmol/L; or a 2-hour postprandial
glucose level 11.1 mmol/L after a 75-gram glucose load or a glycated hemoglobin
(A1C) value of ≥6.5%. In the absence of unequivocal hyperglycemia the test must be
repeated on a different day.

The criteria for impaired glucose homeostasis include either a fasting glucose level of
6.1-6.9 mmmol/L (impaired fasting glucose) or a 2-hour glucose level of 7.8-11
mmol/L on an oral glucose tolerance test or or an A1C of 6.0% to 6.4%. Normal
values are now considered 6.1 mmol/L for fasting glucose and 7.8 mmol/L for the 2-
hour glucose level on an oral glucose tolerance test.

Question #28
QID: 5657
Topic: DM
Subject: Medicine

An 18-year-old male seen in your office is found to be overweight and to have

acanthosis nigricans. Both of his parents have a history of diabetes mellitus. His
fasting plasma glucose level is 6.2 mmol/L. Which one of the following is the correct
diagnosis?
a)  Prediabetes
b)  Type 1 diabetes mellitus
c)  Type 2 diabetes mellitus
d)  Maturity-onset diabetes of the young

The correct answer is a)

Explanation:
This patient has prediabetes, which is defined as having a fasting plasma glucose level
of 5.6 to 6.9 mmol/L.

These patients are at high risk for developing diabetes mellitus later in life.
Prediabetes is associated with metabolic syndrome, and weight loss, exercise, and
certain pharmacologic agents have been shown to prevent or delay the subsequent
development of diabetes mellitus.

Diabetes mellitus is diagnosed in three ways: symptoms of diabetes (polyuria,

polydipsia, unexplained weight loss) plus a random plasma glucose level 11.1
mmol/L; a fasting plasma glucose level 7 mmol/L; or a glucose level 11.1 mmol/L on
a 2-hour 75-g oral glucose tolerance test. It is important to note that in the absence of
unequivocal hyperglycemia the diagnosis must be confirmed by repeat testing on a
subsequent day. Once the diagnosis of diabetes is confirmed, further testing is needed
to differentiate between type 1, type 2, and maturity-onset diabetes of youth.

Question #29
QID: 6105
Topic: DM
Subject: Medicine

In patients with type 2 diabetes mellitus, intensive glycemic control has not been
shown to be beneficial for which one of the following diabetic complications?
a)  Peripheral neuropathy
b)  Foot infections
c)  Cardiovascular disease
d)  Proliferative retinopathy
e)  Nephropathy

The correct answer is c)

Explanation:
Intensive management of hyperglycemia, with a goal of achieving nondiabetic
glucose levels, helps reduce microvascular complications such as retinopathy,
nephropathy, and neuropathy. Foot infections are less common in patients without
neuropathy and in patients with good glycemic control. Intensive management of
hyperglycemia also has a beneficial effect on cardiovascular disease in patients with
type 1 diabetes mellitus but, unfortunately, not in patients with type 2 diabetes
mellitus. In fact, there is data to suggest that intensive glycemic control (hemoglobin
A1c <6.5) may be detrimental in certain populations, such as the elderly and those
with cardiovascular disease.

Question #30
QID: 6160
Topic: DM
Subject: Medicine

A 60-year-old black male is found to have type 2 diabetes mellitus. Which one of the
following should be ordered before initiating treatment with metformin
(Glucophage)?
a)  Serum electrolytes
b)  A serum creatinine level
c)  A CBC
d)  A lipid panel
e)  A thyroid panel

The correct answer is b)

Explanation:
Metformin is contraindicated in patients with renal dysfunction, because it is
associated with an increased incidence of lactic acidosis.

Question #31
QID: 127
Topic: Hyponatremia
Subject: Medicine

A 26-year-old man is admitted to the hospital for lethargy and confusion. The patient
has a 5 year history of severe hypertension that has been refractory to medical
therapy. Over the past few days, the man has become increasingly lethargic and
confused. On the day of admission, he was found in his home, lying on the floor and
non-responsive. His roommate called the ambulance, and the patient was brought to
the ED.
Laboratory values are as follows: 

Serum sodium 112 mmol/L, Normal (135-147 mmol/L)

Serum potassium 5.0 mmol/L, N (3.5-5 mmol/L)
Serum osmolality 230 mmol/kg, N (280-300 mmol/kg)

Which of the following substances is most likely mediating the hyponatremia?  

a)  Aldosterone
b)  Antidiuretic hormone (ADH)
c)  Cortisol
d)  Somatostatin
e)  Thyroid stimulating hormone (TSH)

The correct answer is b)

Explanation:
Hyponatremia is the most common electrolyte abnormality encountered in the
hospital. This patient is clearly hyponatremic. ADH works at the collecting ducts of
the nephron in the kidney to bring back water from the urine into the bloodstream.
This causes both the serum osmolality and serum sodium to drop as the serum
becomes more dilute.

Recall that aldosterone brings back sodium from the urine into the bloodstream and
kicks out serum potassium into the urine. Therefore, high levels of aldosterone would
present as hypokalemia with hypernatremia.

Question #32
QID: 678
Topic: Hyponatremia
Subject: Medicine

A 72-year-old man with a history of recently diagnosed small cell cancer of the lung,
presents to the emergency room following a witnessed, single, tonic-clonic seizure.
His serum sodium is 106 mmol/L.
Which one of the following is the best immediate approach to the management of his
electrolyte disturbance?  

a)  Fluid restriction
b)  Intravenous normal saline at 25 mL/hr
c)  Intravenous normal saline at 100 mL/hr
d)  Intravenous 3% saline at 25 mL/hr
e)  Intravenous 3% saline at 100 mL/hr

The correct answer is e)

Explanation:
This patient most likely has severe syndrome of inappropriate antidiuretic hormone.
Given the presentation, this patient should be treated with Intravenous 3% saline at
100 mL/hr with frequent (q 2 to 4 h) electrolyte determinations (choice E). 

Severe hyponatremia (plasma Na < 109 mmol/L; effective osmolality < 238
mOsm/kg) in asymptomatic patients can be treated safely with stringent restriction of
water intake. However, treatment is more aggressive when neurologic symptoms (eg,
confusion, lethargy, seizures, coma) are present. The debate primarily concerns the
pace and degree of hyponatremia correction.

Many experts recommend that plasma Na be raised no faster than 1 mmol/L/h, but
replacement rates of up to 2 mmol/L/h for the first 2 to 3 h have been suggested for
patients with seizures. Regardless, the rise should be ≤ 10 mmol/L over the first 24 h.
More vigorous correction risks precipitation of osmotic demyelination syndrome.

Hypertonic (3%) saline (containing 513 mmol Na/L) may be used, but only with
frequent (q 2 to 4 h) electrolyte determinations. For patients with seizures or coma, ≤
100 mL/h may be administered over 4 to 6 h in amounts sufficient to raise the serum
Na 4 to 6 mmol/L.

> Fluid restriction (choice A) is incorrect. This patient's history doesn't reveal  that she
was drinking large amount of fluids; while fluid restriction is  normally the initial
treatment for syndrome of inappropriate antidiuretic hormone patients, this is
normally done in asymptomatic patients; once seizures develop, the most preferred
treatment is hypertonic saline.
> Intravenous normal saline (choice B) and (choice C) are incorrect. Treatment for
patients who present with seizure due to hyponatremia is done with hypertonic saline.
> Intravenous 3% saline 25ml/hr (choice D) would be insufficienct to correct the
patient's condition in a timely manner.

Question #33
QID: 6073
Topic: Hyponatremia
Subject: Medicine

A 55-year-old male is brought to the emergency department because of confusion and

seizures. He has a history of hypertension and obstructive sleep apnea due to obesity.
He is not conscious and no other history is available. An examination shows no focal
neurologic findings, but a general examination is limited because of his size. Breath
sounds are diminished, and heart sounds are difficult to hear. He has venous
insufficiency changes on his lower extremities, with brawny-type edema. Laboratory
testing reveals a sodium level of 116 mmol/L (N 135-145), but normal renal and liver
functions. A chest radiograph shows mild cardiomegaly. A BNP level is pending, but
immediate treatment is felt to be indicated.

Which one of the following is the treatment of choice for this patient?
a)  Valsartan (Diovan)
b)  Furosemide
c)  Vasopressin (Pitressin)
d)  Hypertonic saline
e)  Conivaptan (Vaprisol)

The correct answer is d)

Explanation:
This patient has severe hyponatremia manifested by confusion and seizures, a life-
threatening situation warranting urgent treatment with hypertonic (3%) saline. The
serum sodium level should be raised by only 1-2 mmol/L per hour, to prevent serious
neurologic complications. Saline should be used only until the seizures stop. Some
authorities recommend concomitant use of furosemide, especially in patients who are
likely to be volume overloaded, as this patient is, but it should not be used alone. The
arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic
or hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or
who are having seizures.

Question #34
QID: 157
Topic: Hypothyroidism
Subject: Medicine

A patient on lithium therapy develops weakness, lethargy and increased sensitivity to

cold. What investigation must be done?  

a)  Lithium level
b)  TSH level
c)  Reassurance
d)  CBC
e)  CMP

The correct answer is b)

Explanation:
It is well established that lithium therapy can cause hypothyroidism in about 2-3 % of
patients. Once hypothyroidism is diagnosed, treatment of the condition should be
investigated rapidly with thyroxine.

Discontinuation of lithium therapy is an option but in most cases the psychiatric

indication for continuing it is strong, as in this patient. Once treatment is begun,
regular monitoring of TSH and FT4 will be required.
Question #35
QID: 371
Topic: Hypothyroidism
Subject: Medicine

A 38-year-old woman presents to you convinced that she has chronic fatigue
syndrome. The history reveals no evidence of fever or swollen glands, and no other
symptoms other than fatigue and difficulty sleeping. Her physical examination is
completely normal. She has a high thyroid-stimulating hormone level.

You would then suspect and subsequently confirm:  

a)  Hyperthyroidism secondary to pituitary adenoma

b)  Hypothyroidism
c)  Grave's disease
d)  Thyroiditis
e)  Chronic fatigue syndrome

The correct answer is b)

Explanation:
Hypothyroidism is underactivity of the thyroid gland that leads to inadequate
production of thyroid hormone and a slowing of vital body functions.

Insufficient thyroid hormone causes body functions to slow. Symptoms are subtle and
develop gradually. They may be mistaken for depression, especially among older
people. Facial expressions become dull, the voice is hoarse and speech is slow,
eyelids droop, and the eyes and face become puffy. Many people with hypothyroidism
gain weight, become constipated, and are unable to tolerate cold.

Hypothyroidism is common, especially among older people, particularly women; it

affects about 10% of older women. It can, however, occur at any age. Very severe
hypothyroidism is called myxedema.

Diagnosis is made by obtaining TSH and FreeT4 levels. Treatment is with thyroid
replacement with synthroid.

Question #36
QID: 570
Topic: Hypothyroidism
Subject: Medicine

A young woman presents a feature of cold intolerance, fatigue, anorexia, weight gain
and dry skin. Her TSH is increased and freeT4 is low.
What is the most appropriate treatment?  

a)  Beta-blocker
b)  Levothyroxine
c)  Methimazole
d)  Propylthiouracil

The correct answer is b)

Explanation:
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features
such as a typical facies, hoarse slow speech, and dry skin, and by low levels of thyroid
hormones. Management includes treatment of the underlying cause and administration
of thyroxine.

Question #37
QID: 761
Topic: Hypothyroidism
Subject: Medicine

An elderly woman notes the gradual onset of fatigue and feeling tired. She has gained
a significant amount of weight over the last year. She complains frequently that the
house is too cold and is turning up the thermostat. Constipation has become a
problem.

Which of the following is true of this primary condition?  

a)  TSH is depressed
b)  Anti-thyroglobulin antibody are elevated
c)  Anti-thyroid microsomal antibodies are decreased
d)  TRH is elevated
e)  TSH is increased

The correct answer is e)

Explanation:
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features
such as a typical facies, hoarse slow speech, and dry skin, and by low levels of thyroid
hormones. Symptoms may include cold intolerance, constipation, forgetfulness,
fatigue, personality changes and weight gain.

Serum TSH is the most sensitive test. In primary hypothyroidism, there is no feedback
inhibition of the intact pituitary, and serum TSH is always elevated, whereas serum
free T4 is low. In secondary hypothyroidism, free T4 and serum TSH are low.

Question #38
QID: 902
Topic: Hypothyroidism
Subject: Medicine

A 42-year-old woman has recently experienced fatigue, sleepiness, dry skin,

constipation, and a 4.5 kg weight gain. Her thyroid is firm and twice the normal size.

Which one of the following is the most sensitive laboratory test that will be used to
diagnose this patient's condition?  

a)  Serum thyroxine (T4)

b)  Serum triiodothyronine (T3)
c)  T3 resin uptake
d)  Serum thyroid-stimulating hormone (TSH) measurement
e)  Antithyroid antibodies

The correct answer is d)

Explanation:
Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features
such as a typical facies, hoarse slow speech, and dry skin, and by low levels of thyroid
hormones.

Serum TSH is the most sensitive test. In primary hypothyroidism, there is no feedback
inhibition of the intact pituitary, and serum TSH is always elevated, whereas serum
free T4 is low. In secondary hypothyroidism, free T4 and serum TSH are low
(sometimes TSH is normal but with decreased bioactivity). Management includes
treatment of the underlying cause and administration of thyroxine.

Question #39
QID: 980
Topic: Hypothyroidism
Subject: Medicine

A 28 year old woman presents to you with a three month history of fatigue, weight
gain, menstrual irregularity and declining memory. Which of the following laboratory
results is likely in the diagnosis of the underlying problem?  

a)  TSH increased, free T4 increased

b)  TSH decreased, free T4 increased
c)  TSH increased, free T4 decreased
d)  TSH decreased, free T4 decreased
e)  TSH within normal range, free T4 within normal range

The correct answer is c)

Explanation:
Hypothyroidism is common, especially among older people, particularly women; it
affects about 10% of older women. It can, however, occur at any age.

Insufficient thyroid hormone causes body functions to slow. Symptoms are subtle and
develop gradually. They may be mistaken for depression, especially among older
people. Facial expressions become dull, the voice is hoarse and speech is slow,
eyelids droop, and the eyes and face become puffy. Many people with hypothyroidism
gain weight, become constipated, and are unable to tolerate cold. The hair becomes
sparse, coarse, and dry, and the skin becomes coarse, dry, scaly, and thick.

Usually hypothyroidism can be diagnosed with one simple blood test: the
measurement of thyroid-stimulating hormone, which will be high due to a lack of
negative feedback. A second blood test is needed to measure the level of the thyroid
hormone T4 that is not bound by protein (free). A low level confirms the diagnosis of
hypothyroidism.

Question #40
QID: 1181
Topic: Hypothyroidism
Subject: Medicine

A 35 year old woman comes to the physician because of palpitations, restlessness,

sweating, weight loss, and a tremor for the past 6 weeks. Examination shows a fine
tremor, lid lag and stare, and pretibial myxedema. The thyroid gland is diffusely
enlarged, asymmetric, and lobular. A bruit is present over the gland. Laboratory
studies show an undetectable level of thyroid-stimulating hormone, an increased level
of thyroid hormones, and an increased radioactive iodine uptake. The diagnosis of
Graves' disease is made and the treatment options are discussed. The patient selects
radioactive iodine therapy.

This patient is at greatest risk for which of the following conditions?  

a)  Granulocytopenia
b)  Hypothyroidism
c)  Recurrent laryngeal nerve damage
d)  Thyroid carcinoma

The correct answer is b)

Explanation:
Hypothyroidism is the main complication of radioactive iodine therapy, affecting up
to 70% of patients in 10 years. Radioactive iodine therapy is a safe and effective
treatment for Graves' disease because it can provide the same ablative effects of
surgery without the surgical complications. There is no evidence that this treatment
increases the risk for carcinoma.
Question #41
QID: 1250
Topic: Hypothyroidism
Subject: Medicine

A 58-year-old woman is scheduled for an abdominal operation. She has

hypothyroidism that is controlled with thyroid replacement medication and will be
unable to eat or drink for 4 days following the procedure. She is concerned about
receiving her thyroid medication.

She should be advised of which of the following?  

a)  Although she will have symptoms of hypothyroidism, she will not be given the
medication
b)  Although she will not receive the medication, she will have no adverse effects
c)  The medication will be administered daily while the nasogastric tube is clamped
d)  The medication will be discontinued temporarily before the operation
e)  She will receive the medication intravenously

The correct answer is b)

Explanation:
Thyroxine is the hormone of choice for replacement therapy. It has a half-life of seven
days, and any alteration in dose is not reflected for four to six weeks. Therefore, it is
very unlikely that she will develop signs and symptoms of hypothyroidism. She will
not be given the medication either through the nasogastric tube or intravenously, nor
does she require a preoperative loading dose.

Question #42
QID: 5445
Topic: Hypothyroidism
Subject: Medicine

A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central

hypothyroidism secondary to a pituitary adenoma. The nurse practitioner in your
office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0). Which one
of the following would you recommend?
a)  Decrease the dosage of levothyroxine
b)  Increase the dosage of levothyroxine
c)  Order a free T4 level
d)  Order a TRH stimulation test
e)  Repeat the TSH level in 3 months

The correct answer is c)

Explanation:
Although uncommon, pituitary disease can cause secondary hypothyroidism. The
characteristic laboratory findings are a low serum free T4 and a low TSH. A free T4
level is needed to evaluate the proper dosage of replacement therapy in secondary
hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid
replacement in this case, and the low level would prevent the physician from
determining whether the dosage of levothyroxine is appropriate. In the initial
evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if
TSH failed to rise in response to stimulation. It is not necessary in this case, since the
diagnosis has already been made.

Question #43
QID: 5574
Topic: Hypothyroidism
Subject: Medicine

A 67-year-old female presents with progressive weakness, dry skin, lethargy, slow
speech, and eyelid edema. Of the following medications currently taken by this
patient, which one is most likely to be causing her symptoms?
a)  Donepezil (Aricept)
b)  Lithium
c)  Lisinopril (Prinivil, Zestril)
d)  Alendronate (Fosamax)
e)  Glyburide (DiaBeta, Micronase)

The correct answer is b)

Explanation:
This patient has classic signs of hypothyroidism. Of the drugs listed, only lithium is
associated with the development of hypothyroidism. In patients taking lithium, it is
recommended that in addition to regular serum lithium levels, thyroid function tests
including total free T , and TSH be obtained yearly.

Question #44
QID: 8788
Topic: Hypothyroidism
Subject: Medicine

An asymptomatic 55-year-old male visits a health fair, where he has a panel of blood
tests done. He brings the results to you because he is concerned about the TSH level
of 12.0 micro U/mL (N 0.45-4.5). His free T4 level is normal.

Which one of the following is most likely to be associated with this finding?

a)  Atrial fibrillation
b)  Reduced bone density
c)  Systolic heart failure
d)  Elevated LDL cholesterol
e)  Type 2 diabetes mellitus

The correct answer is d)

Explanation:
With subclinical thyroid dysfunction, TSH is either below or above the normal range,
free T4 or T3 levels are normal, and the patient has no symptoms of thyroid disease.
Subclinical hypothyroidism (TSH >10 U/mL) is likely to progress to overt
hypothyroidism. Patients with a serum thyroid-stimulating hormone level greater than
10 μU per mL have a higher incidence of elevated serum low-density lipoprotein
cholesterol concentrations.
Subclinical hyperthyroidism (TSH <0.1 U/mL) is associated with the development of
atrial fibrillation, decreased bone density, and cardiac dysfunction. Neither type of
subclinical thyroid dysfunction is associated with diabetes mellitus. There is
insufficient evidence of benefit to warrant early treatment of either condition.

Question #45
QID: 311
Topic: Addison's Disease
Subject: Medicine

A 35-year-old woman is brought to the ER in severe distress. She has had the "flu" for
three days. Past history reveals a six month history of fatigue and malaise. Physical
exam reveals BP 120/65 mm Hg supine, 90/58 mm Hg standing, and darkened areas
of skin on the knuckles, creases of the palm, elbows and an abdominal scar.
Laboratory values are Na 122 mmol/L, K 5.8 mmol/L, Cl 95 mmol/L, CO2 18
mmol/L.

Which one of the following laboratory tests is most likely to assist in confirming your
diagnosis?  

a)  Plasma follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

b)  24 hour urine metanephrines and vanillylmandelic acid (VMA)
c)  Plasma catecholamines, total and fractionated
d)  Plasma cortisol and adrenocorticotropic hormone (ACTH)
e)  Plasma 17OH progesterone

The correct answer is d)

Explanation:
Addison's disease (adrenal insufficiency) is an insidious, usually progressive
hypofunctioning of the adrenal cortex. It produces various symptoms, including
hypotension and hyperpigmentation, and can lead to adrenal crisis with cardiovascular
collapse.

Diagnosis is clinical and is made by finding elevated plasma ACTH with low plasma
cortisol. Treatment depends on the cause but generally includes hydrocortisone and
sometimes other hormones.

Question #46
QID: 2894
Topic: Addison's Disease
Subject: Medicine

A 40-year-old female presents with the gradual onset of weakness, fatigue, anorexia,
and nausea. She has lost 15 lb (7 kg) over the past 3 months.

A physical examination is unremarkable except for the patient’s tired appearance, a

blood pressure of 90/60 mm Hg, and diffuse hyperpigmentation of the skin and
mucous membranes. Laboratory evaluation includes a sodium level of 130 mmol/L (N
136-145) and a potassium level of 5.8 mmol/L (N 3.5-5.1)

Which one of the following is the best test to further evaluate this patient’s condition?

a)  A TSH level 
b)  A cosyntropin (Cortrosyn) stimulation test 
c)  A plasma ACTH level 
d)  A dexamethasone suppression test

The correct answer is b)

Explanation:
Primary adrenal insufficiency (Addison’s disease) is an uncommon condition in
clinical practice, and typically has an autoimmune etiology. Patients often experience
the insidious onset of weakness, fatigue, and gastrointestinal symptoms. Physical
findings typically include hypotension and diffuse hyperpigmentation of the patient’s
skin and mucous membranes. Due to the loss of aldosterone, serum sodium levels
tend to be low, and hyperkalemia is common.

Cosyntropin is a synthetic analogue of ACTH. The cosyntropin stimulation test is

performed by administering 250 μg of cosyntropin intravenously or intramuscularly
and measuring serum cortisol 30-60 minutes later. A normal response is serum
cortisol > 500 nmol/L. A lower level suggests adrenal insufficiency.

In primary adrenal insufficiency, TSH and ACTH levels may be elevated, but this is
variable and ACTH continues to demonstrate diurnal variation. The dexamethasone
suppression test is used in the evaluation of cortisol excess.
Question #47
QID: 3301
Topic: Addison's Disease
Subject: Medicine

A 54-year-old African-Canadian female is admitted to the hospital for intravenous

heparin therapy for a deep-vein thrombosis of her leg. She had previously been very
healthy. Shortly after admission she begins to experience profound orthostatic
hypotension and gastrointestinal distress. Serial hemoglobin tests are stable, but serum
sodium and bicarbonate levels are low. Her potassium level is slightly elevated.

Which one of the following tests would most quickly determine if she has suffered
from acute adrenal cortex insufficiency (Addison’s disease)?  

a)  A cosyntropin stimulation test

b)  A dexamethasone suppression test
c)  A renin:aldosterone ratio
d)  A serum adrenocorticotropic hormone (ACTH) level
e)  Measurement of 24-hour urinary excretion of catecholamines

The correct answer is a)

Explanation:
Destruction of the adrenal cortex by acute causes (infarction, hemorrhage, infection)
or chronic ones (granulomatous disease, immune destruction) results in a loss of
circulating levels of cortisol and aldosterone. The effects of this deficiency can
include electrolyte disturbances such as those seen in this patient, gastrointestinal
distress (including “acute abdomen,” diarrhea, nausea, etc.), orthostatic hypotension,
and patient fatigue. If the process is gradual, ACTH levels will increase, resulting in a
darkened skin tone. Measuring serum levels of ACTH may be helpful in determining
the cause of decreased cortisol levels, but is not a good first test of adrenal cortex
function. The dexamethasone suppresion test is used to evaluate glucocorticoid
excess.

The cosyntropin stimulation test does assess adrenal cortex function. This test
involves injecting cosyntropin, 250 µg intramuscularly or intravenously, and
measuring cortisol levels 60 minutes later. If the result shows an inadequate response
(cortisol level <495 nmol/L), adrenal cortical function is proven to be at least 90%
diminished.

Question #48
QID: 368
Topic: Pituitary Adenoma
Subject: Medicine

A 30-year-old woman presents with a headache, gradual development of a partial

bitemporal hemianopia, and a history of cessation of menses several years ago.

Which one of the following is the most likely cause?  

a)  Dilated third ventricle

b)  Craniopharyngioma
c)  Saccular aneurysm of the Circle of Willis
d)  Pituitary adenoma
e)  Meningioma of the tuberculum sellae

The correct answer is d)

Explanation:
Enlargement of the pituitary gland is usually due to a tumor but may be due to
bleeding into the gland or involvement by some other disease, such as tuberculosis or
sarcoidosis. An enlarged pituitary gland may produce symptoms such as headaches.

Because the growing gland often presses on the optic nerve, which passes above the
pituitary gland, loss of vision may occur. Vision loss often initially affects only the
upper, outermost fields of vision in both eyes (bitemporal hemianopia).
Underproduction or overproduction of pituitary hormones may also occur. Treatment
depends on the cause of the enlargement.

> Craniopharyngioma occurs most commonly in children but also in men and women
in their 50s and 60s.

Question #49
QID: 2913
Topic: Pituitary Adenoma
Subject: Medicine

A 38-year-old nurse presents with a 6-week history of nervousness, fatigue,

palpitations, and reduced appetite. The physical examination is notable only for lid lag
and a slight diffuse enlargement of her thyroid gland. A laboratory evaluation is
notable for a free T4 level of 8.0 ng/dL (N 0.8-2.7) and a TSH level of 11.4 μU/mL
(N 0.3-4.7).

Which one of the following is the most likely diagnosis?  

a)  Graves’ disease 
b)  Thyroiditis 
c)  Struma ovarii 
d)  Thyrotropin-secreting pituitary adenoma 
e)  Factitious hyperthyroidism
The correct answer is d)

Explanation:
A normal or elevated serum thyrotropin level associated with an elevated free serum
thyroxine level is most consistent with a thyrotropin-secreting pituitary adenoma or a
thyroid hormone resistance syndrome. All of the other conditions listed are associated
with an elevated free thyroxine level, but would result in a suppressed serum
thyrotropin level.

Question #50
QID: 414
Topic: SIADH
Subject: Medicine

A 49-year-old man who smokes two packs of cigarettes a day presents with a lung
mass on x-ray and recent weight gain. Laboratory examination shows hyponatremia
with hyperosmolar urine.

The patient probably has which one of the following diagnoses?  

a)  Renal failure
b)  Pituitary failure
c)  Conn's syndrome
d)  Cardiac failure
e)  Inappropriate ADH (secretion)

The correct answer is e)

Explanation:
SIADH (syndrome of inappropriate secretion of anti-diuretic hormone) is a common
paraneoplastic syndrome that affects the endocrine system. This syndrome is most
often associated with small-cell lung cancer; however, other cancers such as brain
tumors, leukemia, lymphoma, colon, prostate, and head and neck cancers can lead to
SIADH. SIADH is caused by the inappropriate production and secretion of arginine
vasopressin or antidiuretic hormone (ADH) by tumor cells.

Patients with SIADH may not have symptoms, especially in the early stages. When
symptoms do occur they are usually related to hyponatremia, which leads to central
nervous system toxicity if left untreated. Lab values will show concentrated urine in
the presence of plasma hypo-osmolality (hyponatremia).

Signs and symptoms associated with hyponatremia include fatigue, anorexia,

headache and mild alteration in mental status in early stages. If SIADH remains
untreated, symptoms can progress to confusion, delirium, seizures, coma, and death.
Treatment approaches for SIADH are to treat the underlying tumor and restriction of
fluids. More severe cases may require the administration of medications.

Question #51
QID: 999
Topic: SIADH
Subject: Medicine

A 68 year old man presents to the emergency room with a four day history of
worsening headaches and confusion. He is on no medications. Physical examination
confirms the confusion, but is otherwise normal. His plasma sodium is found to be
117 mmol/L (normal 135 - 145 mmol/L) and plasma osmolality is 248 mmol/kg H20
(normal 285 - 295mmol/kg H20).

Which one of the following is the most likely diagnosis?  

a)  Hyperadrenalism
b)  Syndrome of inappropriate antidiuretic hormone secretion
c)  Congestive heart failure
d)  Pseudohyponatremia
e)  Hyperthyroidism

The correct answer is b)

Explanation:
A cause of hyponatremia is the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH). People who have SIADH have a low sodium level because the
pituitary gland secretes too much antidiuretic hormone. Hyponatremia also occurs in
people who have underactive adrenal glands and who thus excrete too much sodium
in the urine. This can result in a low plasma osmolality due to the excess water being
brought back into the bloodstream by the excess ADH.

When the sodium level in the blood falls quickly, symptoms tend to develop rapidly
and be more severe. The brain is particularly sensitive to changes in the sodium level
in the blood. Therefore, symptoms such as lethargy and confusion occur first. As
hyponatremia becomes more severe, muscle twitching and seizures may occur; stupor,
coma, and death may follow. The diagnosis of hyponatremia is made by measuring
the sodium level in the blood.

Question #52
QID: 3251
Topic: SIADH
Subject: Medicine
A 75-year-old white female presents with hyponatremia, with a serum level of 118
mEq/L, a urine osmolality 285 mOsm/kg H2O, and a serum osmolality of 242
mOsm/kg H2O. She complains of some fatigue, but is alert and oriented. Her blood
pressure is 136/82 mm Hg. She has normal thyroid, adrenal, cardiac, hepatic, and
renal function. You admit her to the hospital for treatment and observation.

Which one of the following is the most appropriate initial treatment?

a)  Administration of 3% saline
b)  Administration of normal saline
c)  Free water restriction
d)  Demeclocycline (Declomycin)
e)   Arginine desmopressin

The correct answer is c)

Explanation:
This patient probably has the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH). SIADH can be caused by CNS tumors, various infections such as
meningitis, and pneumonia. Several drugs can cause this condition, including
amiodarone, carbamazepine, SSRIs, and chlorpromazine. Laboratory results in
SIADH show hyponatremia <135 mmol/L, serum osmolality  is usually <
280 mOsm/kg H2O, and is even generally lower than urine osmolality. However, it
should be noted that even if  urine osmolality is lower than serum osmolality, it
should still be considered  abnormally high if it is >100 mOsm/kg H2O in a
hyponatremic patient. Patients with hyponatremia should turn off ADH and have a
urine that is maximally dilute (ie, 50-100 mOsm/kg); however, in patients with
SIADH, the urinary osmolality is usually submaximally dilute (ie, >100 mOsm/kg).
Therefore, if you noticed a patient with hyponatreamia, serum osmolality 240
mOsm/kg H2O, and urine osmolality of 200 mOsm/kg H2O, that patient would still be
having labs consistent with SIADH even if the serum osmolality would be higher than
the urine osmolality.

In this fairly asymptomatic patient we have in the present case, initial management
should be free water restriction (choice C).

> In this asymptomatic patient, hypernatremic saline (choice A) is inappropriate. It is

also important to note that correcting hyponatremia too rapidly may result in central
pontine myelinolysis
> As she is hemodynamically stable, she does not need normal saline.Administration
of normal saline(choice B) may exacerbate the hyponatremia, as the sodium may be
rapidly excreted while the water is retained. If she had a rapid onset and neurologic
symptoms such as seizures, hypertonic saline could be given. Correction should be
slow, with a goal of no more than a 1-2 mmol/L/hr increase in the sodium level; a
normal sodium level should not be reached within the first 48 hours of treatment.
> Demeclocycline (choice D) is appropriate for patients who cannot adhere to the
requirement for fluid restriction, or who have recalcitrant hyponatremia despite
restriction.
> Arginine desmopressin (choice E) is incorrect because the patient already has
inappropriately high ADH and doesn't need supplemental ADH.
Question #53
QID: 5646
Topic: SIADH
Subject: Medicine

You see a patient with a serum sodium level of 122 mEq/L (N 135-145) and a serum
osmolality of 255 mOsm/kg H O (N 280-295). Which one of the following would best
correlate with a diagnosis of syndrome of inappropriate antidiuresis?
a)  Fractional excretion of sodium <1%
b)  Elevated urine osmolality
c)  Elevated serum glucose
d)  Elevated BUN
e)  Low plasma arginine vasopressin

The correct answer is b)

Explanation:
The syndrome of inappropriate antidiuresis (SIAD, formerly SIADH) is related to a
variety of pulmonary and central nervous system disorders in which hyponatremia
and hypo-osmolality are paradoxically associated with an inappropriately
concentrated urine. Most, but not all, cases are associated with increased levels of the
antidiuretic hormone arginine vasopressin (AVP). For a diagnosis of SIAD to be
made, the patient must be euvolemic and not on diuretics (within 24-48 hours), and
the urine osmolality must be high in conjunction with both low serum sodium and low
osmolality. The BUN is normal or low and the fractional excretion of sodium is >1%.

Fluid restriction (<800 cc/24 hours) over several days will correct the
hyponatremia/hypo-osmolality, but definitive treatment requires eliminating the
underlying cause, if possible. In the case of severe, acute hyponatremia with
symptoms (e.g., confusion, obtundation, seizures), hypertonic (3%) saline can be
slowly infused intravenously but can have dangerous neurologic side effects.

Elevated serum glucose levels give rise to a factitious hyponatremia, but not SIAD.

Question #54
QID: 435
Topic: Hyperparathyroidism
Subject: Medicine

While being investigated for long-standing hypertension, a 55 year old woman is

found to have the following serum laboratory test values: normal creatinine, total
protein, albumin, and globulin; increased calcium and alkaline phosphatase, and
decreased phosphorus.
Which of the following do these findings suggest the presence of?  

a)  Carcinoma metastatic to bone

b)  Excessive dietary calcium intake
c)  Multiple myeloma
d)  Parathyroid adenoma
e)  Sarcoidosis

The correct answer is d)

Explanation:
Primary hyperparathyroidism is usually the result of a single benign adenoma. It is a
cause of secondary hypertension.

Elevated parathyroid hormone (PTH) levels in the setting of hypercalcemia establish

the diagnosis of hyperparathyroidism. A decreased serum phosphate level may be
seen. Increased bone turnover may be reflected in elevated levels of markers of bone
formation (alkaline phosphatase) and bone resorption (urinary pyridinoline).

Question #55
QID: 481
Topic: Hyperparathyroidism
Subject: Medicine

A 53-year-old woman presents with lower back pain and increased thirst and
urination. She has nonspecific symptoms of tiredness, easy fatigability, sleep
disturbance and diminished ability to concentrate. Her past medical history is
significant for recurrent calcium oxalate renal stones. Initial labs show an increase in
serum calcium concentration.

What is the most appropriate initial test at this time?  

a)  Bone marrow aspiration

b)  Parathyroid hormone level
c)  MRI of back
d)  Skeletal survey
e)  CT of Head

The correct answer is b)

Explanation:
Primary hyperparathyroidism is one of the most common causes of hypercalcemia
and should be considered in any individual with an elevated calcium level. A single
parathyroid adenoma is the underlying pathology in 85% of cases.
The symptoms have become known as "moans, groans, stones, and bones...with
psychic overtones". They include feelings of weakness and fatigue, depression, or
aches and pains. With more severe disease, a person may have a loss of appetite,
nausea, vomiting, constipation, confusion or impaired thinking and memory, and
increased thirst and urination. Patients may have thinning of the bones without
symptoms, but with risk of fractures.

Elevated parathyroid hormone (PTH) levels in the setting of hypercalcemia establish

the diagnosis of hyperparathyroidism.

Question #56
QID: 1597
Topic: Hyperparathyroidism
Subject: Medicine

A healthy 72 year old female comes to your office for a follow-up visit. She has
hypertension which is well controlled with an ACE inhibitor. Routine laboratory tests
are normal except for a serum calcium level of 10.8 mg/dL (N 8.5-10.5). A repeat
calcium level is 11.1 mg/dL.

Which one of the following would be most appropriate at this point?  

a)  Radiographs of the hands

b)  An osteocalcin level
c)  Order parathyroid hormone (PTH) levels
d)  Bone densitometry
e)  Replace her ACE inhibitor with a Calcium Channel Blocker

The correct answer is c)

Explanation:
In primary hyperparathyroidism, hypercalcemia is the result of excessive PTH
secretion by one or more abnormal, enlarged parathyroid glands. Laboratory findings
in most patients with primary hyperparathyroidism reflect the mild clinical
presentation of the disorder. The serum calcium level is often 1 mg/dL or more above
the upper limits of normal.

>Bone radiographs may show the classic changes of subperiosteal bone resorption in
the occasional patient with hyperparathyroidism, but in most cases they are normal or
may show osteopenia.
>Osteocalcin is an osteoblast-specific protein. It is a marker of increased skeletal
turnover, and it is usually not indicated clinically. The development of highly
sensitive and specific assays for intact, largely active PTH has simplified the
assessment of parathyroid activity.
>Bone densitometry is a test to determine the degree of osteoporosis.
>Hypercalcemia is not a side effect of ACE inhibitor use
Question #57
QID: 2748
Topic: Hyperparathyroidism
Subject: Medicine

Routine blood tests frequently reveal elevated calcium levels. When this evaluation is
associated with elevated parathyroid hormone levels, which one of the following is an
indication for parathyroid surgery?  

a)  Age > 50
b)  Kidney stones
c)  Serum calcium 0.5 mg/dL above the upper limit of normal
d)  Concurrent hyperthyroidism
e)  Increased bone density

The correct answer is b)

Explanation:
Indications for parathyroid surgery include kidney stones, age less than 50, a serum
calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone
density. Hyperthyroidism is not a factor in deciding to perform parathyroid surgery.

Question #58
QID: 2960
Topic: Hyperparathyroidism
Subject: Medicine

Which one of the following is the most common cause of primary

hyperparathyroidism?  

a)  Lithium therapy 
b)  Parathyroid cancer 
c)  Multiple endocrine neoplasia 
d)  An adenoma of a single parathyroid gland

The correct answer is d)

Explanation:
An adenoma of a single parathyroid gland is the cause of primary
hyperparathyroidism in 85% of cases. Other fairly frequent causes are multiple
adenomas and hypertrophy of all four glands. Cancer and multiple endocrine
neoplasias are rare. Lithium therapy may cause hyperparathyroidism, but this is not
considered primary hyperparathyroidism.
Question #59
QID: 5500
Topic: Hyperparathyroidism
Subject: Medicine

A 59-year-old male reports nausea, vomiting, and progressive fatigue for the past few
months. At his last visit, 6 months ago, his blood pressure was poorly controlled and
hydrochlorothiazide was added to his Beta-blocker therapy. At this visit he appears
moderately dehydrated on examination. Laboratory testing reveals a serum calcium
level of 3.19 mmol/L, a BUN level of 12.9 mmol/L and a creatinine level of 220
µmol/L. A CBC, albumin level, and electrolyte levels are normal. His intact
parathyroid hormone level is reported a few days later, and is 60 pg/mL (N 10-65).
What is the most likely cause of his hypercalcemia?
a)  Renal failure
b)  Hyperparathyroidism
c)  Milk alkali syndrome
d)  Sarcoidosis

The correct answer is b)

Explanation:
Many patients have mild hyperparathyroidism that becomes evident only with an
added calcium load. Thiazide diuretics reduce calcium excretion and can cause overt
symptoms in a patient whose hyperparathyroidism would otherwise have remained
asymptomatic. The finding of a normal parathyroid hormone (PTH) level in a patient
with hypercalcemia is diagnostic for hyperparathyroidism, since PTH should be
suppressed in the presence of elevated calcium. Symptomatic hypercalcemia causes
dehydration because of both intestinal symptoms and diuresis. Reversible renal
insufficiency can result, and can become permanent if it is long-standing and severe.

Conversely, renal failure usually causes hypocalcemia, but can cause hypercalcemia
resulting from tertiary hyperparathyroidism. This develops after severe
hyperphosphatemia and vitamin D deficiency eventually produce hypersecretion of
PTH. This patient’s renal insufficiency is not severe enough to cause tertiary
hyperparathyroidism. Milk alkali syndrome is hypercalcemia resulting from a chronic
overdose of calcium carbonate, and is becoming more common as more patients take
calcium and vitamin D supplements. In milk alkali syndrome, and other causes of
hypercalcemia such as sarcoidosis, the PTH level is appropriately suppressed.

Question #60
QID: 5632
Topic: Hyperparathyroidism
Subject: Medicine

A 35-year-old male with a previous history of kidney stones presents with symptoms
consistent with a recurrence of this problem. The initial workup reveals elevated
serum calcium. Which one of the following tests would be most appropriate at this
point?
a)  Serum calcitonin
b)  24-hour urine for calcium and phosphate
c)  Serum phosphate and magnesium
d)  Serum parathyroid hormone
e)  Spot urine for microalbumin

The correct answer is d)

Explanation:
A patient with a recurrent kidney stone and an elevated serum calcium level most
likely has hyperparathyroidism, and a parathyroid hormone (PTH) level would be
appropriate. Elevated PTH is caused by a single parathyroid adenoma in
approximately 80% of cases. The resultant hypercalcemia is often discovered in
asymptomatic persons having laboratory work for other reasons. An elevated PTH by
immunoassay confirms the diagnosis. In the past, tests based on renal responses to
elevated PTH were used to make the diagnosis. These included blood phosphate,
chloride, and magnesium, as well as urinary or nephrogenous cyclic adenosine
monophosphate. These tests are not specific for this problem, however, and are
therefore not cost-effective. Serum calcitonin levels have no practical clinical use.

Question #61
QID: 456
Topic: Diabetes Insipidus
Subject: Medicine

A 48-year-old woman presents with thirst and polyuria in the order of 4-5 L per 24
hours. The urinalysis (urine microscopy) reveals no glucose or albumin and a normal
sediment. The urine specific gravity is 1.001, and the serum sodium 137 mmol/L.
After 8 hours of no fluid intake, the urine specific gravity is 1.001 and the serum
sodium 149 mmol/L.

Which one of the following is the most likely diagnosis?  

a)  Primary polydipsia
b)  Chronic renal failure
c)  Diabetes insipidus
d)  Syndrome of inappropriate antidiuretic hormone secretion
e)   Osmotic diuresis

The correct answer is c)

Explanation:
Diabetes insipidus (DI) results from a deficiency of ADH due to a hypothalamic-
pituitary disorder (central DI) or from resistance of the kidney to ADH (nephrogenic
DI). Polyuria and polydipsia develop. Diagnosis is by water deprivation test showing
failure to maximally concentrate urine, ADH levels and response to exogenous ADH
help distinguish central DI from nephrogenic DI. In patients with central DI,
desmopressin is the drug of choice. Nephrogenic DI is treated with solute restriction
and thiazide diuretics.

Question #62
QID: 581
Topic: Diabetes Insipidus
Subject: Medicine

A patient has a surgery for a pituitary tumor. Post-operatively he develops polyuria.

Which continues with signs of dehydration despite receiving 4 liters of IV fluids.
What is the most appropriate management?  

a)  Give more IV fluids

b)  Start oral rehydration
c)  Give vasopressin (DDAVP)
d)  Give hydrochlorothiazide

The correct answer is c)

Explanation:
This patient likely has developed damage to the pituitary gland which has affected the
release of anti-diuretic hormone (ADH).

Diabetes insipidus (DI) results from a deficiency of ADH due to a hypothalamic-

pituitary disorder (central DI) or from resistance of the kidney to ADH (nephrogenic
DI). Polyuria and polydipsia develop.

Diagnosis is by water deprivation test showing failure to maximally concentrate urine.

ADH levels and response to exogenous ADH help distinguish CDI from NDI.
Treatment for central DI is with desmopressin or vasopressin. Treatment for
nephrogenic DI includes use of diuretics (mainly thiazides).

Question #63
QID: 6238
Topic: Diabetes Insipidus
Subject: Medicine

A 36-year-old female presents with a several-week history of polyuria and intense

thirst. She currently takes no medications. On examination her blood pressure and
pulse rate are normal, and she is clinically euvolemic. Laboratory tests, including
serum electrolyte levels, renal function tests, and plasma glucose, are all normal. A
urinalysis is significant only for low specific gravity. Her 24-hour urine output is >5 L
with low urine osmolality.

The most likely cause of this patient’s condition is a deficiency of:

a)  Angiotensin II
b)  Aldosterone
c)  Renin
d)  Insulin
e)  Arginine vasopressin

The correct answer is e)

Explanation:
This patient has diabetes insipidus, which is caused by a deficiency in the secretion or
renal action of arginine vasopressin (AVP). AVP, also known as antidiuretic
hormone, is produced in the posterior pituitary gland and the route of secretion is
generally regulated by the osmolality of body fluid stores, including intravascular
volume. Its chief action is the concentration of urine in the distal tubules of the
kidney. Both low secretion of AVP from the pituitary and reduced antidiuretic action
on the kidney can be primary or secondary, and the causes are numerous. Patients
with diabetes insipidus present with profound urinary volume, frequency of urination,
and thirst. The urine is very dilute, with osmolality <300 mOsm/L. Further workup
will help determine the specific type of diabetes insipidus and its cause, which is
necessary in order to implement appropriate treatment. Low levels of aldosterone,
plasma renin activity, or angiotensin would cause abnormal blood pressure,
electrolyte levels, and/or renal function. Insulin deficiency results in diabetes mellitus.

Question #64
QID: 467
Topic: Hypercalcemia
Subject: Medicine

An elderly female is on Tamoxifen therapy for advanced breast cancer with bone
metastases. She develops increased thirst, increased urination, disorientation, nausea,
vomiting, confusion and agitation.

What is the most likely cause?  

a)  Tamoxifen side effect

b)  Hypercalcemia
c)  Brain metastasis
d)  SIADH
The correct answer is b)

Explanation:
Hypercalcemia is the most common paraneoplastic syndrome associated with cancer.
Symptoms and signs of hypercalcemia may be noted when total serum Ca is > 12
mg/dL (> 3 mmol/L). These signs can include anorexia, GI reflux, vomiting, lethargy
or seizures or generalized irritability, and hypertension. Other symptoms and signs
include constipation, dehydration, feeding intolerance, and failure to thrive.

Question #65
QID: 816
Topic: Hypercalcemia
Subject: Medicine

A 48-year-old woman receiving chemotherapy for widespread metastatic breast

cancer is admitted to hospital with increasing drowsiness, confusion and constipation.
She is found to be hypercalcemic.

Which one of the following treatment strategies represents the best initial
management of her hypercalcemia?  

a)  Change the chemotherapy regimen

b)  Administer a bisphosphonate drug intravenously
c)  Give normal saline solution and a diuretic together
d)  Give normal saline solution
e)  Give dextrose 5% in water solution

The correct answer is d)

Explanation:
Hypercalcemia is total serum Ca > 12 mg/dL (3 mmol/L), or ionized Ca > 6 mg/dL
(1.5 mmol/L). The most common cause is iatrogenic. GI signs may occur (anorexia,
vomiting, constipation) and sometimes lethargy or seizures.

Treatment: give IV fluids. Then, once the patient is well hydrated, give furosemide
(i.e. a loop diuretic) to cause calcium diuresis. Thiazides are contraindicated because
they increase serum calcium levels. Other treatments include phosphorus
administration (use oral phosphorus; intravenous administration can be dangerous),
calcitonin, diphosphonates, plicamycin, or prednisone. Correction of the underlying
cause of hypercalcemia is the ultimate goal.

Question #66
QID: 1606
Topic: Hypercalcemia
Subject: Medicine

A 65 year old male with known metastatic lung cancer is hospitalized because of
decreased appetite, lethargy, and confusion of 2 weeks’ duration.

Laboratory evaluation reveals the following:

Serum calcium……………….15.8 mg/dL (N 8.4-10.0)

Serum phosphorus……………3.9 mg/dL (N 2.6-4.2)
Serum creatinine……………..1.1 mg/dL (N 0.7-1.3)
Total serum protein…………..7.3 g/dL (N 6.0-8.0)
Albumin……………........……4.1 g/dL (N 3.7-4.8)

Which one of the following is the most appropriate initial management?  

a)  Calcitonin (Calcimar) subcutaneously

b)  Pamidronate disodium (Aredia) by intravenous infusion
c)  Normal saline intravenously
d)  Plicamycin (Mithramycin) intravenously
e)  Furosemide (Lasix) intravenously

The correct answer is c)

Explanation:
Initial management of hypercalcemia of malignancy calls for fluid replacement with
normal saline to correct the volume depletion that is invariably present and to enhance
renal calcium excretion. The use of loop diuretics such as furosemide should be
restricted to patients in danger of fluid overload, since these drugs can aggravate
volume depletion and are not very effective alone in prompting renal calcium
excretion. Although intravenous pamidronate has become the mainstay for the
hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has
been rendered euvolemic by saline repletion. The same is true for the other calcium-
lowering agents listed.

Question #67
QID: 1721
Topic: Hypercalcemia
Subject: Medicine

Which one of the following can contribute to serum calcium elevation?  

a)  Furosemide (Lasix)
b)  Verapamil (Calan, Isoptin)
c)  Enalapril (Vasotec)
d)  Hydrochlorothiazide
e)  Allupurinol (Zyloprim)
The correct answer is d)

Explanation:
While thiazide diuretics do not cause hypercalcemia by themselves, they can
exacerbate the hypercalcemia associated with primary hyperparathyroidism. Thiazides
decrease the renal clearance of calcium by increasing distal tubular calcium
reabsorbtion. Furosemide tends to lower serum calcium levels and is used in the
treatment of hypercalcemia. None of the other medications would be expected to
significantly affect the serum calcium level in this patient.

Question #68
QID: 2907
Topic: Hypercalcemia
Subject: Medicine

Which one of the following is the most likely cause of hypercalcemia in a patient with
hypercalcemia and hyperphosphatemia?  

a)  Vitamin D excess 
b)  Primary hyperparathyroidism 
c)  Humoral hypercalcemia of malignancy 
d)  Exogenous calcitonin administration

The correct answer is a)

Explanation:
The action of parathyroid hormone (PTH) causes phosphate loss through the kidneys;
consequently, hypercalcemia due to PTH excess is usually associated with
hypophosphatemia. Humoral hypercalcemia of malignancy is associated either with
osteolysis, in which case phosphate levels are unaffected, or with elevated levels of a
PTH-related peptide, which would also be associated with hypophosphatemia.
Calcitonin is a weak inhibitor of PTH action and is not associated with hypercalcemia.
Vitamin D increases the gastrointestinal absorption of both calcium and phosphorus;
excess levels are therefore associated with elevated levels of both calcium and
phosphorus. This helps to distinguish vitamin D excess from other causes of
hypercalcemia.

Question #69
QID: 3126
Topic: Hypercalcemia
Subject: Medicine

The initial step in the management of hypercalcemia of malignancy should be:  

a)  fluid restriction
b)  bisphosphonates intravenously
c)  phosphate depletion
d)  aggressive rehydration
e)  diuresis with furosemide (Lasix)

The correct answer is d)

Explanation:
Hypercalcemia of malignancy should be treated initially with aggressive rehydration,
followed by diuresis with furosemide, phosphorus replacement if hypophosphatemia
is present, and intravenous bisphosphonates. Adjunctive therapies include dialysis,
glucocorticoids, calcitonin, plicamycin, and gallium nitrate.

Question #70
QID: 5491
Topic: Hypercalcemia
Subject: Medicine

A 49-year-old female who takes multiple medications has a chemistry profile as part
of her routine monitoring. She is found to have an elevated calcium level. All other
values on the profile are normal, and the patient is not currently symptomatic. Follow-
up testing reveals a serum calcium level of 2.8 mmol/ and a parathyroid hormone
level of 80 pg/mL (N 10-65). Which one of the following should be discontinued for 3
months before repeat laboratory evaluation and treatment?
a)  Lithium
b)  Furosemide (Lasix)
c)  Raloxifene (Evista)
d)  Calcium carbonate
e)  Vitamin D

The correct answer is a)

Explanation:
Lithium therapy can elevate calcium levels by elevating parathyroid hormone
secretion. This duplicates the laboratory findings seen with mild primary
hyperparathyroidism. If possible, lithium should be discontinued for 3 months before
reevaluation (SOR C). This is most important for avoiding unnecessary parathyroid
surgery.

Vitamin D and calcium supplementation could contribute to hypercalcemia in rare

instances, but they would not cause elevation of parathyroid hormone. Raloxifene has
actually been shown to mildly reduce elevated calcium levels, and furosemide is used
with saline infusions to lower significantly elevated calcium levels.

Question #71
QID: 6047
Topic: Hypercalcemia
Subject: Medicine

A 56-year-old male with a history of nephrolithiasis presents with a complaint of right

flank pain. Further evaluation reveals a right ureteral calculus 4 mm in diameter.
Laboratory tests reveal a serum calcium level of 12.1 mg/dL (N 8.5-10.5), a normal
albumin level, and normal kidney and liver function tests. The patient takes no
chronic medications.

Which one of the following is most likely to reveal the cause of this patient’s elevated
calcium?
a)  A 24-hour urine calcium level
b)  A repeat serum calcium level in 4-6 weeks
c)  A serum 25-hydroxyvitamin D level
d)  A serum calcitonin level
e)  A serum intact parathyroid hormone level

The correct answer is e)

Explanation:
Primary hyperparathyroidism and malignancy are the most common causes of
hypercalcemia, accounting for about 90% of cases. An intact parathyroid hormone
(PTH) level should be obtained initially, as the results will indicate what kind of
additional evaluation is needed. Vitamin D and urine calcium studies are useful in
evaluating hypercalcemia, but a PTH level should be obtained first. It would not be
appropriate to wait for a repeat calcium level in 4-6 weeks, because this patient has
nephrolithiasis and a calcium level 12 mg/dL, indicating a possible need for surgery
or perhaps a malignancy. Calcitonin levels generally are not necessary in the
evaluation of hypercalcemia.

Question #72
QID: 6062
Topic: Hypercalcemia
Subject: Medicine

Which one of the following is the best initial management for hypercalcemic crisis?
a)  Intravenous furosemide
b)  Intravenous pamidronate (Aredia)
c)  Intravenous plicamycin (Mithramycin)
d)  Intravenous saline

The correct answer is d)

Explanation:
The initial management of hypercalcemic crisis involves volume repletion and
hydration. The combination of inadequate fluid intake and the inability of
hypercalcemic patients to conserve free water can lead to calcium levels over 14-15
mg/dL. Because patients often have a fluid deficiency of 4-5 liters, delivering 1000
mL of normal saline during the first hour, followed by 250-300 mL/hour, may
decrease the hypercalcemia to less than critical levels (<13 mg/dL). If the clinical
status is not satisfactory after hydration alone, then renal excretion of calcium can be
enhanced by saline diuresis using furosemide. Intravenous pamidronate, a
diphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-
acute setting, since calcium levels do not start to fall for 24 hours. The same is true for
intravenous plicamycin.

Question #73
QID: 11195
Topic: Hypercalcemia
Subject: Medicine

A 60-year-old patient known to have multiple myeloma presents in a state of stupor.

Calcium levels done during this visit show severe hypercalcaemia. What would be the
initial management of severe acute hypercalcaemia in such a patient?

a)  Bisphosphonates
b)  Calcitonin
c)  Saline infusion
d)  Haemodialysis
e)  Glucocorticoids

The correct answer is c)

Explanation:
Saline infusion (choice C) is the first line of management for severe hypercalcaemia.
Hypercalcaemia causes dehydration due to vomiting and/or renal insufficiency.
Hydration on its own can lower calcium levels significantly and alleviates the
stuporous state.

> Bisphosphonates (choice A) take 1-2 days to show reduction in calcium levels. 

> Calcitonin (choice B) can then be added to lower the calcium after aggressive
hydration so as to reduce renal injury.
> Haemodialysis (choice D) is used as a last resort and mainly in patients with renal
insufficiency and heart failure.
> Glucocorticoids (choice E) are useful for hypercalcaemia due to increased
absorption like sarcoidosis.

Saline infusion is the first line of management for severe hypercalcaemia.

Question #74
QID: 480
Topic: Anion Gap
Subject: Medicine

A patient has the following values of Na 140 mmol/L, K 4.0 mmol/L, Cl 100 mmol/L,
HCO3 24 mmol/L. Calculate the anion gap.  

a)  122
b)  40
c)  16
d)  18
e)  64

The correct answer is c)

Explanation:
Anion gap is calculated by the sum of cations minus anions as follows: Anion gap =
(Na+K)-(CL+HCO3). 
However, the potassium is frequently ignored because potassium concentrations,
being very low, usually have little effect on the calculated gap. This leaves the
following equation: 
= ( [Na+] ) − ( [Cl−]+[HCO3−] )

In this question the calculation would be: 140 - (100+24) = 16.

Question #75
QID: 10689
Topic: Anion Gap
Subject: Medicine

An inpatient with advanced liver disease started deteriorating over the last two days.
You were called to see him. His heart rate was 97 per minute, respiratory rate 27 per
minute and blood pressure 100/70 mmHg. You ordered some investigations. You are
presented with the following results:

Serum albumin 20 g/L

serum bicarbonate 14 mmol/L
serum chloride 110 mmol/L
Serum sodium 140 mmol/L

The baseline plasma anion gap of this patient is:

a)  6
b)  10
c)  16
d)  20
e)  26

The correct answer is a)

Explanation:
The question here is not about calculation of plasma anion gap but about the baseline
plasma anion gap (expected normal plasma anion gap). In a patient with normal
plasma albumin, the baseline anion gap is 12 (range 10 - 14). Baseline anion gap
should be decreased by 3 for each 10 g/L fall in serum albumin (from normal average
of 40 g/L). Thus, in this patient baseline anion gap is 6 (12 - 6).
Or use: (0.25 x (44 - albumin)

Correction of baseline plasma anion gap for plasma albumin: baseline anion gap
should be decreased by 3 for each 10 g/L fall in serum albumin.

Question #76
QID: 10706
Topic: Anion Gap
Subject: Medicine

A 66-year-old woman was brought to the hospital unconscious. The woman is a

widow living alone in her room in a residential house, and was found lying on the
floor by the janitor. Her respiratory rate was 27 per minute, heart rate 93 per minute
and blood pressure 110/70 mmHg. Her underwear was soiled with watery fecal
matter. A part from a Glasgow coma scale score of 5, physical examination was
unremarkable. Investigations were ordered and the results of some of these are as
follows:

Blood pH 7.32
PaCO 2 30 mm Hg
Serum bicarbonate 15 mmol/L
Serum sodium 143 mmol/L
Serum chloride 110 mmol/L

Which of the following is least likely to be the cause of metabolic acidosis in this
patient?

a)  Starvation
b)  Alcohol consumption
c)  Methanol poisoning
d)  Salicylate poisoning
e)  Diarrhea

The correct answer is e)

Explanation:
The plasma anion gap of this patient is 18 {143 - (110 + 15)} which is higher than the
normal value of 12 (range 10 to 14). Diarrhea causes metabolic acidosis with normal
anion gap and is unlikely to be the cause of metabolic acidosis in this patient.

 Starvation and excessive alcohol intake lead to accumulation of ketoacids and

would thus, increase the anion gap.
 Because methanol is metabolized to formic acid, it will increase the anion gap
 Salicylate uncouples oxidation and phosphorylation and would lead to
accumulation of endogenous acids. In addition, salicylate itself is an acid. An
increase in the anion gap is then expected.

Use of anion gap in differential causes of metabolic acidosis.

Question #77
QID: 484
Topic: Vitamins
Subject: Medicine

Which of the following vitamins is produced endogenously?  

a)  Vitamin A
b)  Vitamin B6
c)  Vitamin C
d)  Vitamin D

The correct answer is d)

Explanation:
Vitamins are substances that our body needs to grow and develop normally. There are
13 vitamins we need. They are vitamins A, C, D, E, K and the B vitamins (thiamine,
riboflavin, niacin, pantothenic acid, biotin, vitamin B-6, vitamin B-12 and folate).
You can usually get all your vitamins from the foods you eat. Your body can also
make vitamins D and K. People who eat a vegetarian diet may need to take a vitamin
B12 supplement.
Question #78
QID: 1582
Topic: Vitamins
Subject: Medicine

Which one of the following clinical presentations is most consistent with vitamin D
deficiency in the aged?  

a)  Rapidly progressive osteoarthritis

b)  Development of chronic bone pain and weakness in association with bone loss
c)  Bleeding gums and fatigue
d)  High-output cardiac failure with dermatitis and neuropathy
e)  Diarrhea, dermatitis, and dementia

The correct answer is b)

Explanation:
Vitamin D deficiency is being recognized more frequently among the elderly,
especially in the nursing home or other settings where inactivity, nutritional
deficiency, and lack of sunlight exposure combine to increase the propensity for
deficiency. Vitamin D deficiency has been associated with abnormalities in bone
metabolism, primarily osteomalacia. Clinically this can present as muscle weakness,
limb pain, and impaired physical function. Bleeding gums and fatigue may be
presenting symptoms of scurvy (vitamin C deficiency). High-output cardiac failure
with vasodilation, dermatitis, and neuropathy is the clinical presentation of thiamine
deficiency. The combination of diarrhea, scaly dermatitis, and dementia is one of the
clinical presentations of niacin deficiency.

Question #79
QID: 8733
Topic: Vitamins
Subject: Medicine

The daily intake of vitamins and minerals recommended varies according to sex, age,
and condition. The recommended daily allowance of vitamin D is greatest for which
one of the following?

a)  A 15-year-old nonpregnant female

b)  A 25-year-old pregnant female
c)  A 35-year-old lactating female
d)  A 55-year-old female
e)  A 75-year-old female

The correct answer is e)

Explanation:
The current Recommended Dietary Allowance (RDA) for vitamin D is 600 IU/day for
all women between the ages of 9 and 70 years; pregnancy or lactation does not affect
the recommendation. The RDA per day goes up to 800 IU daily for women over the
age of 70. The maximum daily oral intake of vitamin D thought to be safe is 4000
IU/day for all females over the age of 9.

Question #80
QID: 508
Topic: Hypoglycemia
Subject: Medicine

A patient with known type II diabetes mellitus who is treated with Clorpropamide,
presents to ED unconscious. His blood sugar level is very low. You administer 1
ampule of D50 and the patient wakes up promptly.

What is the next appropriate management?  

a)  Give another ampule then discharge

b)  Give 2 ampules then discharge
c)  Give another ampule then observe the patient for 6 hours in the ER
d)  Give one more ampule, admit the patient and start IV glucose infusion with
frequent ongoing glucose measurement

The correct answer is d)

Explanation:
This patient should be admitted. Hypoglycemia causes sweating, nausea, warmth,
anxiety, tremulousness, palpitations, and possibly hunger and paresthesias.
Insufficient glucose supply to the brain causes headache, blurred or double vision,
confusion, difficulty speaking, seizures, and coma. In controlled settings, autonomic
symptoms begin at or beneath a plasma glucose level of about 60 mg/dL (3.33
mmol/L), whereas CNS symptoms occur at or below a glucose level of about 50
mg/dL (2.78 mmol/L).

With severe hypoglycemia patients should be given 50% dextrose 50 to 100 mL IV

bolus, with or without a continuous infusion of 5 to 10% dextrose solution sufficient
to resolve symptoms. Careful monitoring in the inpatient setting is recommended.

Question #81
QID: 681
Topic: Hypoglycemia
Subject: Medicine

A 63-year-old man presents with intermittent neurological abnormalities associated

with hypoglycemia. The patient experiences an attack in the office, and the physician
draws blood for serum insulin, C peptide, and glucose. The attack is relieved by
giving the patient glucose. Laboratory results reveal low serum glucose, high serum
insulin and low serum C peptide.

Which one of the following would result in these clinical and laboratory findings?  

a)  Insulinoma
b)  Reactive hypoglycemia from eating
c)  Glucagonoma
d)  Insulin taken surreptitiously

The correct answer is d)

Explanation:
C-peptide is measured to differentiate insulin produced by the body from insulin
injected into the body. When insulin is synthesized by the beta cells of the pancreas, it
is produced as a large molecule (a propeptide). This molecule is then split into two
pieces: insulin and C-peptide. The function of C-peptide is not known.

The C-peptide level may be measured in a patient with type 1 diabetes to see if any
insulin is still being produced by the body. It may also be measured in the evaluation
of hypoglycemia to see if the person's body is producing too much insulin.

Normal values in a patient requiring insulin injections indicate that the person's body
is still producing some insulin. Normal values in a patient who has low blood sugar
indicate that the patient is making too much insulin.

High levels of C-peptide generally indicate high levels of endogenous insulin

production.
Low levels of C-peptide are associated with low levels of insulin production. This can
occur when insufficient insulin is being produced by the beta cells or when production
is suppressed by exogenous insulin or with suppression tests that involve substances
such as somatostatin.
Question #82
QID: 742
Topic: Hypoglycemia
Subject: Medicine

A 45-year-old woman is brought to the Emergency Department after she fainted in a

supermarket. After evaluation the patient's glucose is found to be 2.5 mmol/l.
Which one of the following criteria is most in favor of the diagnosis of hypoglycemic
disorder?  

a)  Cushing's triad
b)  Whipple's triad
c)  Samter's triad
d)  Virchow's triad
e)   Beck's triad

The correct answer is b)

Explanation:
Hypoglycemia unrelated to exogenous insulin therapy is an uncommon clinical
syndrome characterized by low plasma glucose level, symptomatic sympathetic
nervous system stimulation, and CNS dysfunction. Many drugs and disorders cause it.

 A diagnosis of hypoglycemic disorder can be suggested by the Whipple's triad

(choice B). Essential conditions of this triad are:

 Symptoms are known or likely to be caused by hypoglycemia

 A low plasma glucose measured at the time of the symptoms
 Relief of symptoms when the glucose is raised to normal

> Cushing's triad (choice A) is characterized by bradycardia, bradypnea,  and

hypertension, which are often associated with head injuries.
> Samter's triad (choice C) is seen in aspirin-induced asthma and is characterized by
aspirin sensitivity, nasal polyps,and asthma.
> Virchow's triad (choice D) is composed of stasis, hypercoagulability,  and vessel
injury. It is associated with venous thrombosis.
>  Beck's triad (choice E) is characterized by muffled heart sound, distended neck
veins, and  hypotension; it is diagnostic of cardiac tamponade.

Question #83
QID: 6214
Topic: Hypoglycemia
Subject: Medicine

A 35-year-old white male who has had diabetes mellitus for 20 years begins having
episodes of hypoglycemia. He was previously stable and well controlled and has not
recently changed his diet or insulin regimen.

Which one of the following is the most likely cause of the hypoglycemia?
a)  Spontaneous improvement of beta-cell function
b)  Renal disease
c)  Reduced physical activity
d)  Insulin antibodies

The correct answer is b)

Explanation:
The most common cause of hypoglycemia in a previously stable, well-controlled
diabetic patient who has not changed his or her diet or insulin dosage is diabetic renal
disease. Exogenous insulin is normally metabolized by the kidney. However, when
there is impairment of kidney function, the half-life of insulin is prolonged because of
lower levels of degradation. Therefore, in patients with diabetes (treated with insulin)
and moderate to severe kidney dysfunction, the frequency of hypoglycemic episodes
may be frequent.

> A reduction in physical activity or the appearance of insulin antibodies (unlikely

after 20 years of therapy) would increase insulin requirements and produce
hyperglycemia.
> Spontaneous improvement of beta-cell function after 20 years would be very rare.

Question #84
QID: 610
Topic: Hyperaldosteronism
Subject: Medicine

What is the most sensitive means of differentiating primary from secondary causes of
hyperaldosteronism?
a)  Saline infusion test
b)  Oral salt loading test
c)  Captopril test
d)  Aldosterone-to-renin ratio
e)   Postural testing

The correct answer is d)

Explanation:
The aldosterone-to-renin ratio (ARR) - that is, the ratio of plasma aldosterone to
plasma renin activity (PRA) - is the most sensitive means of differentiating primary
from secondary causes of hyperaldosteronism. It can be obtained under random
conditions of sodium intake. The principle behind this test is that as aldosterone
secretion rises, PRA (which measures the rate of production of angiotensin I from
endogenous angiotensinogen) in ex vivo testing should fall because of sodium
retention. This negative feedback response should occur when the aldosterone levels
are supraphysiologic for that individual patient, and PRA may fall well before plasma
aldosterone is clearly increased. Patients should be normokalemic because
hypokalemia suppresses aldosterone secretion.

> The saline infusion test (choice A) can confirm autonomous aldosterone secretion.
> The oral salt loading test (choice B) consists of administration of sodium chloride
tablets with an ad libitum diet for 3 days, followed by a 24-hour urinary aldosterone
measurement. (increased urinary aldosterone and sodium excretion confirms primary
hyperaldosteronism)
> The captopril test (choice C) has also been used for screening. Its use is based on
the principle that inhibition of angiotensin II production should not affect autonomous
secretion of aldosterone in primary aldosteronism.
> Posural test (choice E) is used for differentiating aldosterone-producing adenoma
from other primary hyperaldosteronism.

Question #85
QID: 744
Topic: Hyperaldosteronism
Subject: Medicine

You are asked to see a 48-year-old male patient because of persistent hypertension
despite taking metoprolol, enalapril and nifedipine. There is no history of palpitations
or flushing, and the patient does not use any nonsteroidal anti-inflammatory drugs.
Blood pressure in your office was found to be elevated at 160/110 mmHg. Recent
laboratory testing shows sodium: 146 mmol/L; potassium: 2.4 mmol/L and creatinine:
85 µmol/L. There is no proteinuria on urinalysis.

Which one of the following is the most appropriate test to arrange at this time?  

a)  Random plasma aldosterone/plasma renin activity ratio

b)  24-hour urine collection for catecholamines and creatinine
c)  24-hour ambulatory blood pressure monitor
d)  24-hour urine collection for cortisol
e)  Nuclear medicine captopril renal scan

The correct answer is a)

Explanation:
Aldosterone, a hormone produced and secreted by the adrenal glands, signals the
kidneys to excrete less sodium and more potassium.
Hyperaldosteronism can be caused by a tumor (usually a noncancerous adenoma) in
the adrenal gland (a condition called Conn's syndrome), although sometimes both
glands are involved and are overactive. Sometimes hyperaldosteronism is a response
to certain diseases, such as very high blood pressure (hypertension) or narrowing of
one of the arteries to the kidneys.

The amount of salt in the diet and medications, such as over-the-counter pain relievers
of the non-steroid class (such as Motrin and Advil), diuretics (water pills), beta
blockers, steroids, angiotensin-converting enzyme (ACE) inhibitors, and oral
contraceptives can affect the test results. You should ask your patient to stop taking
some of his medicines for 2 weeks before the test.

Screening test:
Random plasma aldosterone/plasma renin activity (PRA) ratio - Because this ratio is
fairly constant over many physiologic conditions, it can be used as a screening test.
Normal values are less than 270 when aldosterone concentration is expressed in
pmol/L, or are less than 10 when aldosterone concentration is expressed in ng/dL.

Confirmatory test:
The 24-hour urinary aldosterone (U-Aldo) excretion test is one of the most useful
confirmatory diagnostic tools.

Question #86
QID: 1032
Topic: Hyperaldosteronism
Subject: Medicine

A 34-year-old man is found to have a blood pressure of 180/105 mmHg. He admits to

stress at work and states that his father was diagnosed as hypertensive at the age of 60
but, thus far, has not required treatment. He denies taking any medications. He
smokes 25 cigarettes per day but takes no alcohol. On physical examination he is not
obese, has no signs of cardiovascular disease, and no hypertensive retinopathy. The
results of investigations are given below:

Urine analysis - negative

Na: 146 mmol/L

K: 2.8 mmol/L
Cl: 102 mmol/L
HCO3: 33 mmol/L
Urea: 4.2 mmol/L
Creatinine: 92 mmol/L
Glucose: 6.2 mmol/L

Which of the following investigations is/are indicated?

a)  Dietary intake assessment
b)  Urine metanephrines
c)  CT of chest
d)  Plasma Renin Activity and 24 hour urine collection for aldosterone estimation
e)  Glucose tolerance test
The correct answer is d)

Explanation:
In primary hyperaldosteronism (Conn’s disease), overproduction of aldosterone leads
to fluid retention and increased blood pressure, weakness, and, rarely, periods of
paralysis. Hyperaldosteronism can be caused by a tumor in the adrenal gland or may
be a response to some diseases. High aldosterone levels can cause high blood pressure
and low potassium levels; low potassium levels may cause weakness, tingling, muscle
spasms, and periods of temporary paralysis.
 
If hyperaldosteronism is suspected, both levels of sodium and potassium should be
ordered. Aldosterone levels may also be measured. If they are high, spironolactone or
eplerenone, drugs that block the action of aldosterone, may be given to see if the
levels of sodium and potassium return to normal. In Conn's syndrome, the levels of
renin are also very low.

> Urine metanephrines testing is primarily used to help detect and rule out
pheochromocytomas in symptomatic patients.
> When too much aldosterone is being produced, adrenal glands should be examined
for a noncancerous tumor (adenoma). computed tomography (CT) or magnetic
resonance imaging (MRI) can be helpful.
> Glucose level is normal, glucose tolerance test is not indicated.

Question #87
QID: 1034
Topic: Hyperaldosteronism
Subject: Medicine

A 29 year old has her blood pressure at 180/105 mmHg. She admits to stress at work
and states that her father was diagnosed as hypertensive at the age of 60 but, thus far,
has not required treatment.

The results of investigations are given below:

Na 146 mmol/L
K 2.8 mmol/L
Urea 4.2 mmol/L
Creatinine 92 mmol/L

Which of the following secondary causes of hypertension does this patient most likely
have?  

a)  Coarctation of the aorta

b)  Primary hyperaldosteronism
c)  Renal artery stenosis, bilateral
d)  Renal parenchymal disease
The correct answer is b)

Explanation:
In hyperaldosteronism, overproduction of aldosterone leads to fluid retention and
increased blood pressure. When too much aldosterone is being produced, doctors
examine the adrenal glands for a noncancerous tumor (adenoma).

Question #88
QID: 1940
Topic: Hyperaldosteronism
Subject: Medicine

A patient with ascites is suspected to have secondary hyperaldosteronism. Which of

the following would be typical levels of electrolytes in an aliquot specimen of urine?  

a)  Sodium 2 mEq/L, potassium 40 mEq/L

b)  Sodium 5 mEq/L, potassium 0 mEq/L
c)  Sodium 40 mEq/L, potassium 40 mEq/L
d)  Sodium 80 mEq/L, potassium 2 mEq/L
e)  Sodium 100 mEq/L, potassium 20 mEq/L

The correct answer is a)

Explanation:
Secondary hyperaldosteronism is characterized by sodium retention, and thus
decreased urinary sodium excretion, while potassium secretion is normal to increased.

Question #89
QID: 648
Topic: Hyperkalemia
Subject: Medicine

A patient admitted to the hospital has a basic metabolic panel (BMP) drawn and sent
to the lab. The serum sodium, calcium, and bicarbonate are all normal except the
serum potassium was 6.4 mmol/L. The patient is asymptomatic.
What is the most appropriate next step?  

a)  Dextrose
b)  Repeat the BMP + ECG
c)  Calcium gluconate
d)  Insulin
e)  BUN and Creatinine levels
The correct answer is b)

Explanation:
High levels of potassium in an asymptomatic patient may be due to lab error. To
gather enough information for diagnosis, the measurement of potassium needs to be
repeated, as the elevation can be due to hemolysis in the first sample.

Hyperkalemia is defined as a potassium level greater than 5.5 mmol/L. Ranges are as
follows:
5.5-6.0 mmol/L - Mild
6.1-7.0 mmol/L - Moderate
7.0 mmol/L and greater - Severe

Question #90
QID: 2892
Topic: Hyperkalemia
Subject: Medicine

An 83-year-old male presents with type 2 diabetes mellitus, diabetic nephropathy,

hypertension, and congestive heart failure related to ischemic cardiomyopathy. His
ejection fraction is 25%, and his creatinine clearance is 25 mL/min. You plan to add
an ACE inihibitor to his regimen, but are concerned about the development of
hyperkalemia.

Which one of the following drugs would decrease his risk of hyperkalemia if used
concomitantly with an ACE inhibitor?  

a)  Furosemide (Lasix) 
b)  Naproxen (Naprosyn) 
c)  Celecoxib (Celebrex) 
d)  Spironolactone (Aldactone) 
e)  Propranolol (Inderal)

The correct answer is a)

Explanation:
The geriatric population is at increased risk of hyperkalemia associated with the use
of ACE inhibitors, especially in the presence of renal disease. Drugs that increased
this risk, if used concomitantly with an ACE inhibitor, including β-blockers, NSAIDs
(including selective COX-2 inhibitors), and potassium-sparing diuretics. Other
diuretics, such as furosemide, enhance excretion of potassium by increasing delivery
of sodium to the collecting duct.
Question #91
QID: 2941
Topic: Hyperkalemia
Subject: Medicine

A previously healthy 42-year-old male who is not on any medications has blood
drawn for a routine preemployment evaluation. Laboratory studies are normal except
for a potassium level of 5.4 mmol/L (N 3.5-5.0).

Which one of the following would be the most appropriate next step?  

a)  Obtain an EKG to rule out T-wave abnormalities 

b)  Repeat the blood sample collection 
c)  Prescribe oral sodium polystyrene sulfonate (Kayexalate) and recheck the
potassium level in 2 days 
d)  Administer intravenous calcium 
e)  Administer intravenous insulin following by an inhaled β2-agonist

The correct answer is b)

Explanation:
Given the absence of underlying renal problems or medication use, the most likely
cause of this patient’s elevated potassium level is pseudohyperkalemia.
Pseudohyperkalemia occurs when the laboratory value does not accurately reflect
actual serum values. The most common cause is lysis of red blood cells during
phlebotomy collection. It can be excluded by repeating the blood sample collection as
nontraumatically as possible.

Potassium values less than 6mEq/L are not usually clinically significant and do not
cause EKG changes. Treatment with sodium polystyrene sulfonate, intravenous
calcium, intravenous insulin, and/or an inhaled β2-agonist are necessary only if
pseudohyperkalemia has been ruled out and/or there are clinical indicators such as
EKG changes, a rapid rise of serum potassium, decreased renal function, and/or
significant acidosis.

Question #92
QID: 3318
Topic: Hyperkalemia
Subject: Medicine

An asymptomatic 38-year-old white male takes lisinopril (Prinivil, Zestril) for

hypertension. At a routine follow-up visit you order a basic metabolic profile. The
results are normal except for a serum potassium level of 6.3 mEq/L (N 3.5-5.0).
Which one of the following should you do at this point?  

a)  Order another serum potassium level but make sure the patient repeatedly clenches
his
fist during the phlebotomy
b)  Order another metabolic profile but make sure the sample stands for several hours
before being centrifuged
c)  Reassure the patient that the potassium elevation is likely due to a laboratory error
and
disregard the result
d)  Temporarily discontinue the lisinopril and order a repeat potassium level

The correct answer is d)

Explanation:
Pseudo-hyperkalemia is most commonly caused by lysis of red cells released from
platelets in clotted serum. Clenching the fist repeatedly can aggravate red cell
damage. As the patient is on an ACE inhibitor that can raise potassium levels,
reassurance without investigation would not be appropriate. A plasma potassium level
does not reflect potassium released from cells damaged by phlebotomy.

Question #93
QID: 5488
Topic: Hyperkalemia
Subject: Medicine

A 75-year-old female is admitted to the hospital with a change in mental status. The
initial workup includes a chemistry profile that reveals a plasma potassium level of
6.4 mEq/L (N 3.7-5.2). Which one of the following should be given now to rapidly
lower the plasma potassium level?
a)  Corticosteroids
b)  Albuterol
c)  Sodium polystyrene sulfonate
d)  0.45% saline
e)   Acute hemodialysis

The correct answer is b)

Explanation:
Severe hyperkalemia (>6.0 mEq/L) requires aggressive treatment. Calcium gluconate
has no effect on the plasma potassium level, but it should be given first, as it rapidly
stabilizes the membranes of cardiac myocytes, reducing the risk of cardiac
dysrhythmias.
Therapies that translocate potassium from the serum to the intracellular space should
be instituted next, as they can quickly (albeit temporarily) lower the plasma
concentration of potassium. These interventions include sodium bicarbonate, glucose
with insulin, and albuterol.
Total body potassium can be lowered with sodium polystyrene sulfonate, but this
takes longer to affect the plasma potassium level than translocation methods. In the
most severe cases, acute hemodialysis can be instituted.

Question #94
QID: 11405
Topic: Hyperkalemia
Subject: Medicine

A known diabetic patient presents to emergency department with oliguria and high
blood pressure. With appropriate work-up, the diagnosis of acute renal failure is
established. His plasma glucose and serum potassium are 17 mmol/L and 7.2 mmol/L,
respectively.

Which of the following treatments is expected to lower plasma potassium?

a)  Oral elemental calcium

b)  Intravenous calcium gluconate
c)  Insulin
d)  Angiotensin converting enzyme inhibitor
e)  Intravenous propranolol

The correct answer is c)

Explanation:
Insulin (choice C) is expected to lower blood potassium and is indicated in the
treatment of patients with severe hyperkalemia (serum potassium > 7.0 mmol/L).
Insulin stimulates Na+/H+ /antiporter increasing intracellular sodium. This increase in
intracellular sodium stimulates the Na+/K+ ATPase, which would pump potassium
into the cells lowering plasma potassium. A drop of plasma potassium up to 1.5
mmol/L can be achieved with administration of 10 to 20 units of regular insulin and
the effect can last for several hours. In this patient, glucose administration is not
required because blood glucose is already high.

> Calcium whether given orally (choice A) or intravenously (choice B) does not lower
plasma potassium. However, IV calcium is the first line treatment of severe
hyperkalemia. Calcium does not lower plasma potassium but counteracts the effects
of hyperkalemia. Specifically, high extracellular calcium decreases excitability of
nerve and muscles cells by raising threshold potential, the membrane potential at
which an all or none action potential develops.
> Angiotensin converting enzyme inhibitor (ACEI) (choice D) may worsen
hyperkalemia by inducing secondary hypoaldosteronism. Aldosterone stimulates
secretion of potassium in exchange for sodium in the collecting ducts or the renal
tubules. Indeed if this patient is on an ACEI, this drug should be discontinued not
only because it might worsen hyperkalemia but also because it interrupts
glomerulotubular balance and might compromise recovery of renal function.
> Intravenous propranolol (choice E), beta-2-adrenergic blocker, may also worsen
hyperkalemia. But, beta-2-adrenergic agonists, such as adrenaline, can lower plasma
glucose. Thus, beta-blockers should not be used in treating hypertension in this
patient.

Key point:
In addition to treatment of diabetes mellitus, insulin can also be used in treatment of
sever hyperkalemia.

Question #95
QID: 711
Topic: Primary Polydipsia
Subject: Medicine

An 18-year-old girl presents with thirst and polyuria in the order of 4-5 L per 24
hours. The urinalysis (urine microscopy) reveals no glucose or albumin and a normal
sediment. The urine specific gravity is 1.001, and the serum sodium 137 mmol/L.
After 8 hours with no fluid intake, the urine specific gravity is 1.024 and the serum
sodium 141 mmol/L.
Which one of the following is the most likely diagnosis?  

a)  Primary polydipsia
b)  Chronic renal failure
c)  Neurogenic (central) diabetes insipidus
d)  Nephrogenic diabetes insipidus
e)  Syndrome of inappropriate antidiuretic hormone (ADH) secretion

The correct answer is a)

Explanation:
Primary polydipsia, also termed psychogenic diabetes insipidus, or compulsive water
drinking. It is a condition in which the subject experiences a powerful need to ingest
fluid and presents with polyuria and polydipsia and a plasma osmolarity lower than
the normal, perhaps as low as or lower than 270 mOsm/L. The synthesis, secretion,
nephron sensitivity to ADH and the osmoreceptor response are all intact and operative
in these subjects.

The hallmark of this disease, is plasma hypo-osmolarity in the presence of polyuria

and the ability to form a maximally concentrated urine when deprived of water or
when ADH is administered. As noted above in central or nephrogenic diabetes
insipidus the polyuria precedes and is the cause of the polydipsia. In the case of
psychogenic diabetes insipidus the polydipsia precedes and is the cause of the
polyuria.

Question #96
QID: 795
Topic: Hyperthyroidism
Subject: Medicine

A 30-year-old woman presents with complaints of heat intolerance, sleeplessness,

nervousness and weight loss despite an excellent appetite.
What changes in TSH and free T4 would you most likely expect to see?  

a)  Decreased TSH, increased free T4

b)  Increased TSH, increased free T4
c)  Decreased TSH, normal free T4
d)  Increased TSH, decreased free T4
e)  Normal TSH, increased free T4

The correct answer is a)

Explanation:
Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of
free thyroid hormones. Symptoms are many but include tachycardia, fatigue, weight
loss, and tremor.

Diagnosis is based on history, physical examination, and thyroid function tests. Serum
TSH is the best test, because TSH is suppressed in hyperthyroid patients except when
the etiology is a TSH-secreting pituitary adenoma or pituitary resistance to thyroid
hormone. Free T4 is increased.

Question #97
QID: 2903
Topic: Hyperthyroidism
Subject: Medicine

A 27-year-old female complains of palpitations and heat intolerance. She had similar
symptoms before being diagnosed with hyperthyroidism and treated with
propylthiouracil. The propylthiouracil was discontinued 6 weeks ago by an
emergency department physician because the patient developed a rash. The rash
resolved and the patient did not keep a recommended follow-up appointment with
you.

On physical examination, the patient’s pulse is 134 beats/min and regular, her blood
pressure is 136/58 mm Hg, and her temperature is 36.9˚C (98.4˚F). The thyroid is
diffusely enlarged without nodularity. The skin is moist and a fine tremor is present.
The examination is otherwise unremarkable.

Which one of the following is most likely to be effective for initial symptom control?

a)  Propranolol (Inderal) 
b)  Potassium iodide (SSKI) 
c)  Verapamil (Calan, Isoptin) 
d)  Adenosine (Adenocard) 
e)  Diltiazem (Cardizem)

The correct answer is a)

Explanation:
Symptoms of hyperthyroidism including palpitations, heat intolerance, tachycardia,
and tremor are largely mediated by increased adrenergic activity. Propranolol is useful
for treating the symptoms of mild hyperthyroidism. It is effective in decreasing
tachycardia and tremor and also has a role in the treatment of thyroid storm. At high
doses it blocks conversion of T4 to T3, in addition to providing β-blockade.

Antithyroid agents such as propylthiouracil are useful, but require an extended period
for symptom control. Potassium iodide should not be used until antithyroid therapy
with an agent such as propylthiouracil has been instituted. It is most frequently used
as part of the treatment of thyroid storm.

Calcium channel blockers such as diltiazem and verapamil may be useful in slowing
supraventricular arrhythmias by blocking conduction at the AV node. They are not
useful for the adrenergically triggered sinus tachycardia of hyperthyroidism.
Adenosine has similar but transient effects on the AV node.

Question #98
QID: 5509
Topic: Hyperthyroidism
Subject: Medicine

A 26-year-old female presents with a 2-month history of amenorrhea, nausea, and

fluttering in her chest. The fluttering feels similar to what she experienced 3 years ago
when diagnosed with Graves’ disease. At that time, she was successfully treated with
medication, which she discontinued after 18 months. Current laboratory tests reveal a
positive hCG, a TSH of 0.03 micro U/mL (N 0.4-5.0), and a free T4 of 4.0 micro g/dL
(N 0.8-2.0). Which one of the following would be the most appropriate treatment in
this situation?
a)  131 Iodine ablation
b)  Propylthiouracil
c)  Subtotal thyroidectomy
d)  Methimazole (Tapazole)

The correct answer is b)

Explanation:
Overt hyperthyroidism causes an increase in neonatal morbidity from preterm birth
and low birth weight. Propylthiouracil should be considered the treatment of choice
because methimazole may be associated with congenital anomalies. 131I is
contraindicated in pregnancy because of radiation dangers to the fetus, as well as
thyroid destruction. Although subtotal thyroidectomy is a viable treatment option, it is
recommended only if medical therapy is unsuccessful.

Question #99
QID: 6164
Topic: Hyperthyroidism
Subject: Medicine

Which one of the following is known to cause hyperthyroidism?

a)  Propranolol (Inderal)
b)  Amiodarone (Cordarone)
c)  Methimazole (Tapazole)
d)  Propylthiouracil
e)  Methotrexate (Rheumatrex, Trexall)

The correct answer is b)

Explanation:
Amiodarone is 37% iodine and is the most common source of iodine excess in
Canada. Excessive iodine intake from dietary sources, radiographic contrast media, or
amiodarone increases the production and release of thyroid hormone in iodine-
deficient individuals and in older persons with multinodular goiter. Additionally, like
other medications such as interferon and interleukin-2, amiodarone can trigger
thyroiditis in patients with normal thyroid glands. These characteristics combine to
induce hyperthyroidism in slightly over 10% of patients treated with amiodarone. -
Blockers such as propranolol may be useful in controlling the symptoms of
hyperthyroidism. Methimazole and propylthiouracil interfere with organification of
iodine, thereby suppressing thyroid hormone production; they are commonly used as
antithyroid agents when treating hyperthyroidism. Research is ongoing to determine if
methotrexate plus prednisone is an effective treatment for the ophthalmopathy
associated with Graves’ hyperthyroidism.

Question #100
QID: 10885
Topic: Hyperthyroidism
Subject: Medicine

Four weeks ago a patient presented to her family physician with palpitations and heat
intolerance. With proper work-up, she was diagnosed as a case of Grave’s Disease.
She was treated accordingly. Today, she comes back for follow-up. Adjustment of the
dose of her antithyroid medication should be based on the serum level of:

a)  TSH
b)  Total thyroxine (T4)
c)  Total triiodothyronine (T3)
d)  Free thyroxine (T4)
e)  Free triiodothyronine (T3)

The correct answer is d)

Explanation:
Serum free T4 is the test of choice for titration of the dose of antithyroid medications
because of its high sensitivity to the activity of the thyroid gland. This high sensitivity
reflects the fact that T4 is the major product of the gland. T4 represents the biologically
active form of thyroxine and is the source of most circulating T3.

 Due to sustained elevation of thyroid hormones levels in hyperthyroidism due

to Grave’s disease, TSH (choice A) secretion remains suppressed for several
months. Serum TSH is, thus, an insensitive index of treatment response and
not suitable for titration of the dose of the antithyroid medication used.
 Several factors including diseases and medications can affect the serum levels
of thyroid hormone binding proteins and binding of T3 and T4 to these proteins.
These factors are thus expected to affect serum levels of total T3 and
T4 (choices B and C) and make them less specific indices of treatment
response and less suitable for titration of the dose of antithyroid medication
compared to free T4 level.
 Unlike T4 , most T3 in blood is not produced by the thyroid gland but instead
by deiodination of T4 in the peripheral tissues. This process of deiodination
can be modified by other disease and medications and could further reduce the
specificity of serum total T3 to the effect of treatment. Because serum free T3 is
a proportion of serum total T3, the level of serum free T3 (choice E) is also a
less specific index of treatment response compared to free T4 level.

Key point:
Although serum TSH is the most sensitive test for diagnosing hyperthryoidism, it is
insensitive for evaluating the effect of treatment and titration of the dose of
antithyroid medications. Free T4 should be used instead.

Question #101
QID: 866
Topic: FSH
Subject: Medicine

Low to normal follicle-stimulating hormone levels (FSH) are found in patients with:
a)  Resistant ovary syndrome
b)  Previous pelvic radiotherapy for cervical cancer
c)  Anorexia nervosa
d)  Pure gonadal dysgenesis
e)  Premature ovarian failure

The correct answer is c)

Explanation:
A low caloric intake not only interferes with the nutritional needs of a young and
growing organism, but also interferes with the homeostatic mechanisms necessary to
maintain functioning. Undernutrition and weight loss associated with anorexia
nervosa either reverse pubertal changes and prevent menarche from occurring
(primary amenorrhea) or regress the hypothalamic-pituitary-gonadal axis to
prepubertal regulation, resulting in low LH, low FSH and minimal estrogen and
progesterone plasma levels (secondary amenorhhea).

Question #102
QID: 1099
Topic: Hypokalemia
Subject: Medicine

A 62 year old woman who is a regular patient calls the office because she has
developed severe muscle weakness, muscle cramps and polyuria. She began treatment
6 weeks ago with 50 mg of chlorthalidone daily for mild-to-moderate essential
hypertension.

The most likely explanation for her symptoms is the development of which of the
following?  

a)  Diabetes mellitus
b)  Hypokalemia
c)  Hypomagnesemia
d)  Hyponatremia
e)  Metabolic acidosis

The correct answer is b)

Explanation:
Hypokalemia is a very common side effect of nonpotassium-sparing diuretics (e.g.,
chlorthalidone). This is often more pronounced in the older age group. Patients
usually complain of muscle weakness, fatigue, and cramps. Constipation and ileus
characterize the smooth muscle involvement, whereas hyporeflexia, flaccid paralysis,
and tetany are signs of severe hypokalemia.
Question #103
QID: 1139
Topic: Diabetic Ketoacidosis
Subject: Medicine

In the course of DKA, serum potassium levels:  

a)  Remain unaffected
b)  Can appear normal but total body potassium may actually be low
c)  Can appear normal but total body potassium may actually be high
d)  Will naturally be corrected by insulin administration
e)   None of the above

The correct answer is b)

Explanation:
In the course of DKA, serum potassium levels can appear normal but total body
potassium may actually be low. 

Potassium loss is caused by a shift of potassium from the intracellular to the

extracellular space in an exchange with hydrogen ions that accumulate extracellularly
in acidosis. Much of the shifted extracellular potassium is lost in urine because of
osmotic diuresis. This will make it seem like the serum body potassium is
normal. Patients with initial hypokalemia are considered to have severe and serious
total body potassium depletion.

Question #104
QID: 1154
Topic: Hyperlipidemia
Subject: Medicine

A 51 year old woman presents to her physician for follow up of a fasting serum
cholesterol level of 13.5 mmol/L. She is post-menopausal since age 49, and has not
been on hormone replacement therapy. She has a positive family history for coronary
artery disease and she has smoked one-half pack of cigarettes per day for the past 15
years. Today she would like to know the results of her full lipid panel.

Which of the following lipid panels would most strongly suggest the need for
pharmacologic therapy in this patient?  

a)  Total cholesterol 5.2 mmol/L, LDL 4 mmol/L

b)  Total cholesterol 10.2 mmol/L, LDL 3 mmol/L
c)  Total cholesterol 12.6 mmol/L, LDL 6.2 mmol/L
d)  Total cholesterol 8.4 mmol/L, LDL 3.2 mmol/L

The correct answer is c)

Explanation:
For those patients in whom a fasting panel has been obtained, a stepwise approach to
intervention based on the patient's LDL and risk factors may be used. A patient with
2+ risk factors (this patient) and an LDL of greater than 4.13 mmol/L warrants
medical therapy.

Question #105
QID: 2017
Topic: Hyperlipidemia
Subject: Medicine

A 52 year old white male is being considered for pharmacologic treatment of

hyperlipidemia because of an LDL cholesterol level of 180 mg/dL.

Before beginning medication for his hyperlipidemia, he should be screened for:  

a)  Hyperthyroidism
b)  Hypothyroidism
c)  Addison’s disease
d)  Cushing’s disease
e)  Pernicious anemia

The correct answer is b)

Explanation:
According to the Summary of the National Cholesterol Education Program (NCEP)
Adult Treatment Panel III Report, any person with elevated LDL cholesterol or any
other form of hyperlipidemia should undergo clinical or laboratory assessment to rule
out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of
secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver
disease, chronic renal failure, and some medications.

Question #106
QID: 3209
Topic: Hyperlipidemia
Subject: Medicine

A mildly hypertensive 54-year-old male with type 2 diabetes asks about the benefit of
adding fish oil capsules to his daily medication regimen of atorvastatin (Lipitor),
metformin (Glucophage), and aspirin.

You advise that fish oil supplements have been shown to:  
a)  increase the risk of rhabdomyolysis
b)  lower triglycerides
c)  decrease cardiovascular risks in the general population
d)  have antiarrhythmic properties
e)  improve glycemic control

The correct answer is b)

Explanation:
The omega-3 polyunsaturated fatty acids found in fish oil have been shown to lower
plasma triglycerides and reduce the risk of stroke after a myocardial infarction.

Unlike niacin and gemfibrozil, they do not increase the risk of rhabdomyolysis in
statin patients. However, they may worsen glycemic control in diabetics and have a
proarrhythmic effect in coronary artery disease patients. There is no evidence that fish
oil supplements prevent coronary disease in the general population.

Question #107
QID: 6237
Topic: Hyperlipidemia
Subject: Medicine

A 52-year-old white male is being considered for pharmacologic treatment of

hyperlipidemia because of an LDL-cholesterol level of 4.5mmol/L (180 mg/dL).
Before beginning medication for his hyperlipidemia, he should be screened for:
a)  Hyperthyroidism
b)  Hypothyroidism
c)  Addison’s disease
d)  Cushing’s disease
e)  Pernicious anemia

The correct answer is b)

Explanation:
According to the National Cholesterol Education Program Adult Treatment Panel III
Report of 2001, any person with elevated LDL cholesterol or any other form of
hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary
dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary
dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease,
chronic renal failure, and some medications.

Question #108
QID: 1196
Topic: Thyroid Disease
Subject: Medicine

Which of the following is associated with thyroid disease?

a)  Neurofibromatosis
b)  Vitiligo
c)  Erythema nodosum
d)  Pemphigus vulgaris
e)  Icthyosis vulgaris

The correct answer is b)

Explanation:
Vitiligo is a loss of skin melanocytes that causes areas of skin depigmentation of
varying sizes. Cause is unknown, but the condition may be autoimmune, as up to 1/3
of patients have evidence of other autoimmune disease. Vitiligo affects 0.5 to 2% of
the population. Etiology is unknown, but melanocytes are lacking in affected areas;
some patients have antibodies to melanin. Up to 30% have other autoimmune
antibodies (to thyroglobulin, adrenal cells, and parietal cells) or clinical autoimmune
endocrinopathies (Addison's disease, diabetes mellitus, pernicious anemia, and
thyroid dysfunction), leading to speculation that vitiligo is an autoimmune disease.
However, the relationship is unclear and may be coincidental. The strongest
association is with hyperthyroidism (Graves' disease) and hypothyroidism
(Hashimoto's thyroiditis).

Question #109
QID: 2037
Topic: Thyroid Disease
Subject: Medicine

Chronic excess thyroid hormone replacement over a number of years in

postmenopausal women can lead to:  

a)  Diffuse nontoxic goiter

b)  Osteoarthritis
c)  Osteoporosis
d)  Hyperparathyroidism

The correct answer is c)

Explanation:
Even mild chronic excess thyroid hormone replacement over many years can cause
bone mineral resorption, increase serum calcium levels, and lead to osteoporosis.

>The elevated calcium decreases parathyroid hormone.

>Goiter is an indicator, not a cause, for hormone replacement.
>Osteoarthritis is not related to thyroid hormone replacement.

Question #110
QID: 3341
Topic: Thyroid Disease
Subject: Medicine

Which one of the following is the most accurate and cost-effective screening
procedure for thyroid disease in geriatric patients?

a)  Serum T3
b)  Serum free T4
c)  Radioactive iodine (RAIU) uptake
d)  Serum TSH
e)  Radioallergosorbent test (RAST)

The correct answer is d)

Explanation:
Physicians should consider periodic screening for biochemical abnormalities in
elderly patients, because a clinical presentation of thyroid disease is not reliable in this
age group. The most effective way to screen for thyroid dysfunction is to order a TSH
level with third-generation assays using an immunoradiometric assay (IRMA). The
RAST test is used for allergy testing. Notably, the College of Physicians recommends
periodic screening only for women age 50 and older. Other organizations have
varying guidelines.

Question #111
QID: 1212
Topic: Graves Disease
Subject: Medicine

A 28-year-old woman comes to the office because of fatigue, weakness and

palpitations. She is divorced and lives with her 4 year old daughter. Complete
evaluation shows that this patient has hyperthyroidism and mild ophthalmopathy
caused by Graves disease. Before initiating therapy, the patient wants to know what
she can expect in the future.

In advising her about the prognosis, the most accurate statement is:  

a)  Graves ophthalmopathy will resolve as thyroid hormone secretion is lowered

b)  Malignant degeneration of the thyroid is a common complication
c)  She will not be able to become pregnant
d)  The thyroid will continue to increase in size with any nonsurgical treatment
e)  Untreated patients are at increased risk for cardiac arrhythmias

The correct answer is e)

Explanation:
Hyperthyroid patients are at increased risk for cardiac arrhythmias, typically
tachyarrhythmias. Graves’ ophthalmopathy follows a course that is independent of
thyroid disease. Malignant degeneration is not a complication of Graves disease.
Hyperthyroidism does not preclude the ability to become pregnant. There is no
evidence to suggest that every Graves thyroid increases in size without surgery.

Question #112
QID: 5640
Topic: Graves Disease
Subject: Medicine

A 33-year-old white female presents with tremor and a history of weight loss. On
examination she is found to have mild, regular tachycardia and exophthalmos.
Laboratory tests confirm hyperthyroidism. Which one of the following treatments has
been found to potentially worsen ophthalmopathy?
a)  Radioactive iodine
b)  Propylthiouracil
c)  Methimazole (Tapazole)
d)  Thyroid hormone replacement plus propylthiouracil
e)  Thyroidectomy

The correct answer is a)

Explanation:
The ophthalmopathy of Graves’ disease may initially flare and worsen when treated
with radioactive iodine. Antithyroid drugs, including carbimazole, propylthiouracil,
and methimazole, are not associated with this problem. The addition of thyroid
hormone to these drugs at suppressive doses has not shown any clear benefit over
titration of the antithyroid drug, and relapse rates are similar. Thyroid surgery in the
controlled patient has not been significantly associated with this problem.

Question #113
QID: 6099
Topic: Graves Disease
Subject: Medicine

In a patient with symptoms of thyrotoxicosis and elevated free thyroxine (T4), and the
presence of thyroid-stimulating thyrotropin receptor antibodies would indicate which
one of the following as the cause of thyroid gland enlargement?
a)  Toxic multinodular goiter
b)  Toxic adenoma
c)  Hashimoto’s (lymphadenoid) thyroiditis
d)  Subacute (giant cell) thyroiditis
e)  Graves’ disease

The correct answer is e)

Explanation:
Graves’disease is characterized by thyroid stimulating autoantibodies directed against
the thyrotropin receptor leading to receptor activation in the absence of
TSH. Thyroid-stimulating immunoglobulins (TSI) bind to and activate thyrotropin
receptors, causing the thyroid gland to grow and the thyroid follicles to increase
synthesis of thyroid hormone. Detection of TSIs is diagnostic for Graves disease.
Patients usually present with symptoms typical of thyrotoxicosis. Hyperthyroidism is
characterized by both increased sympathetic and decreased vagal modulation.
Tachycardia and palpitation are very common symptoms. Free T4 level is usually
elevated, as is the free T3 level.

> A toxic nodular goiter is a thyroid gland that contains autonomously functioning
thyroid nodules, with resulting hyperthyroidism. It is not associated with autoimmune
thyroiditis.
> A thyroid adenoma is a benign tumor of the thyroid gland. Almost all thyroid
adenomas are follicular adenomas. Toxic thyroid adenoma produces excessive thyroid
hormone but is not associated with autoimmune thyroiditis.
> Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases and is
characterized by the destruction of thyroid cells by various cell- and antibody-
mediated immune processes. Laboratory studies show low total T4 or free T4 level in
the presence of an elevated TSH level and hyroid autoantibodies: typically anti-
thyroid peroxidase and anti-thyroglobulin antibodies.
> Subacute thyroiditis is a self-limited thyroid condition (not associated with
autoimmune thyroiditis) associated with a triphasic clinical course of
hyperthyroidism, hypothyroidism, and return to normal thyroid function. Subacute
thyroiditis may be responsible for 15-20% of patients presenting with thyrotoxicosis
and 10% of patients presenting with hypothyroidism.

Question #114
QID: 10905
Topic: Graves Disease
Subject: Medicine

A 40-year-old female presents because she has noticed a neck mass and complains of
weight loss despite normal appetite. She denies pain, hair loss, and constipation.
Exopthalmos is noted on physical examination. What is the most likely diagnosis?

a)  TSH secreting pituitary adenoma

b)  Medications induced disorder
c)  Diffuse toxic goiter
d)  Toxic multinodular goiter
e)  Hashimoto thyroiditis

The correct answer is c)

Explanation:
This patient’s clinical presentation with weight loss, neck mass, and exophthalmos
combined together are suggestive of Graves disease, which is diffuse toxic goiter
(choice C). It is an autoimmune disease characterized by hyperthyroidism due to
circulating autoantibodies. The thyroid gland is under continuous stimulation by
circulating autoantibodies against the thyrotropin receptor, and pituitary thyrotropin
secretion is suppressed because of the increased production of thyroid hormones.
Almost every organ system can be affected by Graves disease. Patients may present
with warm and moist skin, sweating, tremors, palpitations, chest pain, photophobia,
polyuria, heat intolerance, amenorrhea, and irritability. Out of the choices given, no
other diagnosis would have the clinical presentation of this patient.

> TSH secreting pituitary adenoma (choice A) represents only 2% of pituitary

microadenomas. While central hyperthyroidism has many symptoms associated with
hyperthyroidism similar to Graves disease, it also presents with additional symptoms
related to the pressure effects of a pituitary adenoma such as loss of vision or other
types of visual defects. Therefore, based on presentation and statistics (frequency),
Graves disease has a greater likelihood to be diagnosed.
> Medications induced disorder (choice B) is incorrect. While drugs such as
amiodarone can cause hyperthyroidism, exophthalmos is not associated with drug
induced thyroid disease.
> Toxic multinodular goiter (choice D) may similarly present with hyperthyroidism
associated symptoms but it is not known to cause exophthalmos.
> Hashimoto thyroiditis (choice E) is the most common cause of hypothyroidism,
while it may have a brief hyperthyroid state, it is unlikely to cause exophthalmos.

Key point:
Neck mass, symptoms associated with hyperthyroidism, and exopthalmos are
suggestive of diffuse toxic goiter also known as Graves disease.

Question #115
QID: 1566
Topic: Obesity
Subject: Medicine

When considering therapy for the obese patient, one should know that the major
component of caloric expenditure is:  

a)  Dietary thermogenesis (the energy required for metabolism of food)

b)  The basal metabolic rate (the amount of energy required to maintain metabolic
homeostasis)
c)  Physical activity
d)  The negative-feedback response of growth hormone and cortisol to the ingestion
of food

The correct answer is b)

Explanation:
When caloric intake is greater than energy expenditure, obesity results. The major
components of caloric expenditure are the basal metabolic rate, dietary thermogenesis,
and physical activity. The basal metabolic rate (the amount of energy required to
maintain metabolic homeostasis) accounts for 60%-70% of caloric expenditure.
Dietary thermogenesis (the energy required for digestion and metabolism of food)
accounts for 5%-10% of caloric expenditure and depends upon the amount and type
of food eaten and, to an extent, on the degree of obesity. Physical activity accounts for
about 25%-35% of caloric expenditure in the average person.

Question #116
QID: 1591
Topic: Diagnostic Investigations
Subject: Medicine

Of the following, the best laboratory study to evaluate nutritional status in an elderly
patient is:  

a)  Folate levels
b)  Iron studies
c)  Serum creatinine
d)  Serum albumin
e)  Serum electrolytes

The correct answer is d)

Explanation:
Serum albumin is sensitive to changes in nutritional status, although its long half-life
(17-21 days) means that return to normal is slow. A lymphocyte count provides a
quick estimate of immune status and low counts may indicate a need for nutritional
assessment. Iron studies are more likely to be abnormal as a result of gastrointestinal
blood loss. Folate level mostly reflect generic nutritional deficiency, rather than a
specific deficiency. A low folate level is consistent with consumption of a limited
variety and quantity of food. Electrolyte levels do not reflect nutrition.

Question #117
QID: 1638
Topic: Diagnostic Investigations
Subject: Medicine

Hemoglobin A1C assays are inaccurate in patients with:  

a)  Secondary hypertension
b)  Morbid obesity
c)  Cor pulmonale
d)  Sickle cell disease
e)  Hypothyroidism

The correct answer is d)

Explanation:
The glycosylated hemoglobin assay is rendered inaccurate by conditions affecting red
blood cell survival, such as sickle cell disease or the presence of hemoglobin C.

Question #118
QID: 3169
Topic: Diagnostic Investigations
Subject: Medicine

A 26 year old white female with regular periods presents to your office with
complaints of excessive hair growth. An examination reveals moderately increased
facial and body hair.

Which one of the following studies would you order initially to evaluate androgen
excess?  

a)  Dehydroepiandrosterone
b)  FSH
c)  Free testosterone
d)  Prolactin
e)  17 alpha-hydroxyprogesterone

The correct answer is c)

Explanation:
With mild hirsutism, regular menses, and no features to suggest a secondary cause, it
is reasonable to forgo laboratory evaluation given the very high likelihood that the
hirsutism is idiopathic. About half of women with moderate or severe hirsutism have
androgen excess. The initial step in the workup should be measurement of plasma free
testosterone in the early morning, ideally between days 4 and 10 of the menstrual
cycle. If free testosterone is abnormal, further workup would include an evaluation for
an underlying cause.

The 2002 ACOG guidelines on hirsutism state that dehydroepiandrosterone sulfate

levels should be measured only in cases of rapid virilization. If testosterone is
elevated, ACOG recommends measurement of thyrotropin, prolactin, and early-
morning levels of 17 alpha-hydroxyprogesterone to rule out other androgen-excess
disorders. ACOG suggests considering evaluation for Cushing’s syndrome and other
rare disorders only with suggestive symptoms or signs.

If this woman with hirsutism had reported irregular menses consistent with
anovulation, polycystic ovary syndrome (PCOS) should be suspected as the cause of
her androgen excess and hirsutism. The workup for PCOS should include evaluation
for glucose intolerance and metabolic syndrome.

Question #119
QID: 3284
Topic: Diagnostic Investigations
Subject: Medicine

A 60-year-old white female is in the intensive-care unit for respiratory failure

secondary to community-acquired pneumonia. She smokes 2 packs of cigarettes per
day, but has no other significant medical or personal history. A medical student is
making rounds with you and asks if the patient’s thyroid function should be tested.

Which one of the following is true regarding thyroid testing in this situation?  

a)  Most patients who are critically ill should be tested for occult hypothyroidism
b)  Serum TSH is a good screening test for thyroid disease in critically ill patients
c)  low TSH level in this patient would indicate hyperthyroidism
d)  A low T4 level is a frequent finding in patients hospitalized in the intensive-care
unit
e)  A low T3 level should be treated with thyroid replacement in hospitalized critically
ill
patients

The correct answer is d)

Explanation:
Many patients hospitalized with nonthyroid illness in the intensive care unit have
abnormalities on thyroid testing. Low serum concentrations of both thyroxine (T4) and
triiodothyronine (T3) are common, and TSH may be decreased as well. Thyroid
function should not be assessed in seriously ill patients unless a thyroid problem is
strongly suspected. Measurement of serum TSH alone is inadequate for the evaluation
of thyroid function in critically ill patients.

Question #120
QID: 5629
Topic: Diagnostic Investigations
Subject: Medicine

A 45-year-old male was admitted to the hospital for nausea resulting from
chemotherapy for colon cancer. He has no other chronic diseases and takes no routine
medications. He was mildly dehydrated on admission and has been receiving
intravenous fluids (D5 ½-normal saline with potassium chloride) at slightly higher
than maintenance rates through an indwelling port for the last 24 hours. The nausea is
being controlled by antiemetics, and his condition is improving. Results of routine
blood work at the time of admission and from the following morning are shown
below. 

                               Admission                                   Following Morning

Glucose              109 mg/dL (N 65-110)                371 mg/dL

BUN                     13 mg/dL (N 7-21)                      9 mg/dL
Creatinine           0.9 mg/dL (N 0.6-1.6)                 0.9 mg/dL
Sodium                143 mmol/L (N 136-144)            129 mmol/L
Potassium           3.7 mmol/L (N 3.6-5.1)               6.6 mmol/L
Chloride               110 mmol/L (N 101-111)            108 mmol/L
Total CO               220 mmol/L (N 22-32)                22 mmol/L

Which one of the following would be the most appropriate next step?
a)  Start an intravenous insulin drip
b)  Order blood work taken from a peripheral vein
c)  Restrict the patient’s free water intake
d)  Switch from normal saline to hypertonic saline
e)  Treat with diuretics

The correct answer is b)

Explanation:
You should avoid reacting to laboratory values without considering the clinical
scenario. This patient presented with mild dehydration and normal laboratory values.
Although he is improving clinically, his laboratory values show multiple unexpected
results. The most noticeable is the severely elevated glucose, because he has no
history of diabetes mellitus or use of medications that could cause this effect.
Similarly, the elevated potassium and decreased sodium suggest profound electrolyte
abnormalities. Most likely, the laboratory technician drew blood from the patient’s
indwelling port without discarding the first several milliliters. Thus, the blood was
contaminated with intravenous fluids, resulting in the erroneous results. A repeat
blood test from a peripheral vein should give more accurate results.

Question #121
QID: 6026
Topic: Diagnostic Investigations
Subject: Medicine
Which one of the following is the best diagnostic test for vitamin D deficiency?
a)  Ionized calcium
b)  Serum phosphorus
c)  24-hour urine for calcium
d)  1,25-hydroxyvitamin D
e)  25-hydroxyvitamin D

The correct answer is e)

Explanation:
Undiagnosed vitamin D deficiency is not uncommon, and 25-hydroxyvitamin D is the
barometer for vitamin D status. Although there is no consensus on optimal levels of
25-hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by most
experts as a 25-hydroxyvitamin D level of <20 ng/mL (50 nmol/L).

Question #122
QID: 6167
Topic: Diagnostic Investigations
Subject: Medicine

A 36-year-old female consults you because of concerns about “fatigue.” After

carefully reviewing her history and performing a physical examination, which one of
the following would be least valuable in assessing this patient?
a)  A baseline serum cortisol level
b)  Complete blood count
c)  A complete metabolic panel
d)  A TSH level
e)  A pregnancy test

The correct answer is a)

Explanation:
In patients with fatigue, you should complete an appropriate history and physical
examination. Laboratory studies should be considered, although the results affect
management in only 5% of patients. A baseline cortisol level would be valuable only
in patients with significant findings of Addison’s disease. In addition to an
erythrocyte sedimentation rate, a complete metabolic panel, and a TSH level, many
physicians request a CBC and a urinalysis. A pregnancy test should be ordered for
women of childbearing age. No other tests have been shown to be useful unless a
specific medical condition is suspected.
Question #123
QID: 1611
Topic: Hypernatremia
Subject: Medicine

Physiologic changes in the elderly lead to which one of the following?  

a)  Resistance to dehydration
b)  A tendency toward hypernatremia due to diminished thirst response
c)  Lower than usual concentrations of medications distributed in body fluids
d)  Greater than usual required dosages of medications

The correct answer is b)

Explanation:
There is no known resistance to dehydration in the elderly. There is a smaller volume
of dilution for drugs distributed in body fluids. This may result in higher
concentrations of medications, sometimes approaching toxic levels, especially if the
usual adult dosages are given. Because elderly patients have a diminished thirst
response, they are prone to develop hypernatremia when water is not immediately
available.

Question #124
QID: 1779
Topic: Thyrotoxicosis
Subject: Medicine

Which one of the following is a cause of thyrotoxicosis characterized by a decreased

radioactive iodine uptake?  

a)  Graves' disease
b)  Subacute thyroiditis
c)  Toxic multinodular goiter
d)  Solitary toxic thyroid nodule

The correct answer is b)

Explanation:
Thyrotoxicosis with a high 24-hours radioactive iodine uptake (RAIU) is caused by
Graves’ disease, toxic multinodular goiter, a solitary hot nodule, a TSH-secreting
pituitary tumor, molar pregnancy, and choriocarcinoma. Thyrotoxicosis with a low
24-hour RAIU may be the result of subacute thyroiditis, sporadic silent thyroiditis,
postpartum lymphocyctic thyroiditis, radiation-induced thyroiditis, iodine-induced
thyroiditis, thyrotoxicosis factita, metastatic follicular thyroid cancer, and struma
ovarii.
Question #125
QID: 1904
Topic: Adverse Drug Effect
Subject: Medicine

Which one of the following is more likely to occur with glipizide (Glucotrol) than
with metformin (Glucophage)?  

a)  Lactic acidosis
b)  Hypoglycemia
c)  Weight loss
d)  Gastrointestinal distress

The correct answer is b)

Explanation:
Metformin is a biguanide used as an oral antidiabetic agent. One of its main
advantages over some other oral agents is that it does not cause hypoglycemia. Lactic
acidosis, while rare, can occur in patients with renal impairment. In contrast to most
other agents for the control of elevated glucose, which often cause weight gain,
metformin reduces insulin levels and more frequently has a weight-maintaining or
even a weight loss effect. Gastrointestinal distress is a common side-effect of
metformin, particularly early in therapy.

Question #126
QID: 2879
Topic: Adverse Drug Effect
Subject: Medicine

When used to lower total serum cholesterol, nicotinic acid tends to:

a)  Increase serum triglycerides 

b)  Increase serum glucose 
c)  Increase LDL cholesterol 
d)  Increase the LDL/HDL cholesterol ratio 
e)  Decrease HDL cholesterol

The correct answer is b)

Explanation:
Nicotinic acid lowers total serum cholesterol, LDL cholesterol, serum triglycerides,
and the LDL/HDL ratio. It increase HDL cholesterol. It worsens glucose control, and
is therefore not a good choice for use in diabetics.
Question #127
QID: 2924
Topic: Adverse Drug Effect
Subject: Medicine

Which one of the following forms of glucocorticoid therapy is most likely to result in
hypothalamic-pituitary-adrenal axis suppression?

a)  Split-dose oral therapy with a bedtime dose 

b)  Morning single-dose oral therapy 
c)  Alternate-day oral therapy 
d)  Topical therapy 
e)  Intra-articular injection therapy

The correct answer is a)

Explanation:
Late evening doses of glucocorticoid are more likely to suppress the normal early
morning ACTH surge. They should be avoided because of the increased risk of
suppressed adrenal secretion.

One-daily morning dosing is less likely to result in adrenal suppression. If short-

acting drugs such as hydrocortisone are used, the last dose of the day should not be
taken after 5 pm. Alternate-day therapy is less likely to suppress the hypothalamic-
pituitary-adrenal axis. It is frequently less therapeutically effective. Topical and intra-
articular therapy rarely result in adrenal suppression.

Question #128
QID: 2957
Topic: Adverse Drug Effect
Subject: Medicine

A 62-year-old white male has a history of coronary artery disease, hypertension, and
osteoarthritis. He is on lovastatin (Mevacor) for hypercholesterolemia. You are
choosing a medication to treat his hypertension.

Which one of the following could increase this patient’s risk of rhabdomyolysis?  

a)  Carvedilol (Coreg) 
b)  Quinapril (Accupril) 
c)  Losartan (Cozaar) 
d)  Atenolol (Tenormin) 
e)  Verapamil (Calan, Isoptin)

The correct answer is e)

Explanation:
Lovastatin, as well as other statin cholesterol-lowering medications, is primarily
metabolized through the cytochrome P-450 system. Medications that inhibit the
enzyme CYP 3A4, such as verapamil, increase serum concentrations of selected
statins and subsequently increase the risk of rhabdomyolysis.

Question #129
QID: 3175
Topic: Adverse Drug Effect
Subject: Medicine

A 67 year old male presents with symptoms of decreased libido and erectile
dysfunction. An evaluation reveals that he has primary testosterone deficiency, and
you consider testosterone replacement therapy.

Which one of the following is true regarding this therapy?  

a)  Liver toxicity is common

b)  It decreases the rate of bone fractures
c)  The risk of prostate cancer is increased
d)  HDL cholesterol levels typically increase
e)  Erythrocytosis is a potential side effect

The correct answer is e)

Explanation:
When testosterone is taken at usual physiologic doses, liver toxicity is unusual.
Testosterone replacement therapy may stop bone loss and increase bone density, but
many studies have been equivocal, and none have reported a decreased rate of
fractures. Although prostate cancer is thought to be stimulated by testosterone, no
studies have shown convincing evidence of an increased risk of prostate cancer
associated with testosterone therapy. Studies indicate that testosterone therapy either
has no effect on HDL cholesterol or reduces HDL cholesterol levels. Testosterone
stimulates erythropoiesis in 3%-18% of men receiving testosterone therapy. Since
polycythemia is a potential issue, hemoglobin levels should be monitored.

Question #130
QID: 5423
Topic: Adverse Drug Effect
Subject: Medicine

A 30-year-old female comes to your clinic with the complaints of palpitations.

The symptoms started 3 weeks ago. She also complains of weight loss, increased
appetite and heat intolerance. Her vital signs are within normal limits except for a
pulse of 100/min. Physical exam shows that her thyroid gland is diffusely enlarged.

You order thyroid function tests which show low TSH, high T4 and T3. After proper
counseling, the patient refuses surgery or radioactive iodine ablation. You prescribed
propylthiouracil for her. Which of the following is the most common potentially life
threatening side effect of this medication?
a)  Hypocalcemia
b)  Liver failure
c)  Renal failure
d)  Serious infection
e)  Stomach cancer

The correct answer is d)

Explanation:
No blood! No Drug! Patients taking propylthiouracil for a long time should be
followed routinely with blood tests “CBC with differential” to guard against the
potentially life threatening agranulocytosis which could put the patient at risk for
disseminated infections.

Liver necrosis and failure is a possible side effect for propylthiouracil; however it is
very rare to occur. Always read the statement of the question carefully; we are asking
for the most common one. Do not let them fool you on the exam!

Hypocalcemia is a common side effect following thyroidectomy.

Renal failure and stomach cancer are not associated with propylthiouracil.

Question #131
QID: 5543
Topic: Adverse Drug Effect
Subject: Medicine

Which one of the following is associated with testosterone supplementation in men

with hypogonadism?
a)  Muscle wasting
b)  Polycythemia
c)  Osteoporosis
d)  Hyperlipidemia
e)  Increased fat mass

The correct answer is b)

Explanation:
Testosterone increases hematocrit and can cause polycythemia. In patients receiving
testosterone supplementation, hematocrit should be monitored every 6 months for the
first 18 months, then annually. Testosterone should be discontinued if there is more
than a 50% rise in hematocrit. Testosterone also causes an increase in lean body mass,
and may increase bone density and increase PSA. No major unfavorable effects on
lipids were reported.

Question #132
QID: 6080
Topic: Adverse Drug Effect
Subject: Medicine

Which one of the following decreases the absorption of orally administered calcium
supplements?
a)  Taking calcium carbonate with meals
b)  Taking calcium citrate with meals
c)  Vitamin D supplementation
d)  Proton pump inhibitors

The correct answer is d)

Explanation:
Long-term histamine H -blocker or proton pump inhibitor use is associated with
decreased absorption of 2 calcium carbonate. Patients taking these medications who
require calcium supplementation should use calcium citrate to improve absorption.
Calcium carbonate preparations should be given with a meal to improve absorption.
Vitamin D is important in calcium absorption.

Question #133
QID: 6165
Topic: Adverse Drug Effect
Subject: Medicine

A 20-year-old college wrestler is seen for an examination prior to the wrestling

season. He tells you that some friends have told him he should start taking
dehydroepiandrosterone (DHEA), and he asks for your advice.
Which one of the following is true about the effects of this drug?
a)  It enhances performance but not muscle strength
b)  It enhances muscle strength but not performance
c)  It enhances both performance and muscle strength
d)  It does not enhance either performance or muscle strength

The correct answer is d)

Explanation:
Dehydroepiandrosterone (DHEA) is illegal under the Anabolic Steroid Control Act of
2004, and is prohibited by the NCAA and the International Olympic Committee. Like
androstenedione, DHEA is a precursor to testosterone, but neither of these substances
has been shown to enhance either performance or strength. In fact, they increase
serum estrogen and luteinizing hormone levels.

Question #134
QID: 2976
Topic: Insulin Therapy
Subject: Medicine

For which one of the following insulins does the onset of action occur within 15
minutes, with peak action occurring within about 1 hour?
a)  NPH 
b)  Regular insulin (Novolin R, Humulin R) 
c)  Lispro (Humalog) 
d)  Lente (insulin zinc suspension) 
e)  Glargine (Lantus)

The correct answer is c)

Explanation:
The traditional bolus or mealtime insulin is regular insulin that has an onset of action
within 30-60 minutes and peaks in 2-3 hours. As a result, regular insulin must be
injected 30-60 minutes before meals. In order to avoid this problem, analogue insulins
have been created by substituting 1-3 amino acids in the human insulin protein, which
allows for altered absorption rates and more reliable absorption profiles. The analogue
forms of bolus or mealtime insulin include lispro and asparte. Both of these begin
acting within 15 minutes and peak in about 1 hour, mimicking normal mealtime
insulin release. NPH, lente, and glargine are all basal insulins with a longer onset,
peak, and duration of action.

Question #135
QID: 2872
Topic: Hypophosphatemia
Subject: Medicine

An elderly alcoholic male is brought to the hospital by his grandson, who found him
in poor condition. The grandson reports that his family has not seen the patient in
months.

The patient denies complaints, but is obviously malnourished, poorly washed, and
mildly intoxicated. You admit the patient to the hospital and begin providing
supportive care, including intravenous fluids with dextrose, a regular diet, and
physical therapy evaluation. On the evening of the second day he becomes weak and
more confused. His blood pressure is 88/56 mm Hg, and he has a seizure. Your
evaluation includes the following laboratory findings:

                                 Glucose…………………………….....…..60 mg/dL (N 70-110)

                                 BUN……………………………….............9 mg/dL (N 6-20)
                                 Creatinine……………………....…….…..2.6 mg/dL (N 0.8-1.3)
                                 Creatine kinase………….…..............…..480 U/L (N 38-174)
                                 Troponin I…………………….....………..<0.1 ng/mL (N<0.6)
                                 Albumin……………………………......….2.7 g/dL (N 3.4-4.8)
                                 Calcium…………………………...…..…..8.2 mg/dL (N 8.6-
10.0)
                                 Phosphate…………………….…….........0.7 mg/dL (N 2.7-4.5)
                                 ALT (SGPT)……………………..........…..68 U/L (N 10-40)
                                 AST (SGOT)………………….........……..88 U/L (N 10-30)

This episode is most likely related to abnormal levels of which one of the following?  

a)  Glucose 
b)  Creatinine 
c)  Creatine kinase 
d)  Calcium 
e)  Phosphate

The correct answer is e)

Explanation:
Severe hypophosphatemia is a medical emergency. In poorly nourished patients,
refeeding syndrome can occur. Symptoms usually occur by the second or third day of
improved nutrition, and are often multisystemic. Findings may include weakness,
confusion, dysrhythmias, respiratory failure, congestive heart failure, hypotension,
ileus, metabolic acidosis, seizures, coma, and sudden death. This constellation of
problems results from decreased insulin secretion as stores of intracellular phosphate
become depleted. Providing carbohydrates through intravenous fluids or refeeding
increases insulin secretion, which stimulates cells to take up phosphate, causing
severe hypophosphatemia. In this setting cells are unable to produce enough 2,3
diphosphoglycerate and adenosine triphosphate to meet metabolic demands

While hypoglycemia is another medical emergency, this patient’s glucose level is not
low enough to cause these symptoms. Similarly, renal failure of some type is present,
as is an elevated creatinine kinase suggesting rhabdomyolysis; however, neither of
these problems would be expected to cause this patient’s symptoms. Hypocalcemia
can cause multisystemic problems, including weakness and seizures, but this level is
not critically low and is not associated with hypotension.

Question #136
QID: 3277
Topic: Hypophosphatemia
Subject: Medicine

A 31-year-old male with type 1 diabetes mellitus is admitted to the hospital with
diabetic ketoacidosis and pneumonia. After initial treatment in the emergency
department with intravenous fluids and insulin, laboratory tests reveal a serum
phosphate level of 2.1 mg/dL (N 2.5-5.0). He is asymptomatic except for related
pneumonia symptoms.

Which one of the following would be appropriate management of this patient’s low
serum phosphate level?  

a)  No therapy
b)  Oral phosphate replacement, 2.5-3.5 g/day in divided doses
c)  Oral phosphate replacement, 2.5-3.5 g/day in divided doses, and oral vitamin D
supplementation, 400-800 IU/day
d)  Intravenous phosphate replacement, 0.08-0.16 mmol/kg over 6 hours

The correct answer is a)

Explanation:
Symptomatic hypophosphatemia rarely occurs unless serum phosphate levels are
below 2.0 mg/dL. Serious symptoms, including rhabdomyolysis, do not occur until
serum phosphate concentrations fall below 1.0 mg/dL. Thus, treatment of
hypophosphatemia with phosphate levels greater than or equal to 2.0 mg/dL is
targeted at an underlying etiology.

Hypophosphatemia in diabetic ketoacidosis cases is related to the internal

redistribution of phosphate from extracellular fluid during treatment, and will resolve
when normal dietary intake resumes (choice A).

> Phosphate supplementation (choice B and choice C) in this setting has not been
shown to be beneficial.
> Intravenous administration (choice D) of phosphate can be dangerous, resulting in
the precipitation of calcium and producing the adverse effects of hypocalcemia, renal
failure, and possibly fatal arrhythmias.
Question #137
QID: 2920
Topic: Metabolic Syndrome
Subject: Medicine

The metabolic syndrome responds best to:  

a)  Thyroid hormone therapy 

b)  Antioxidants 
c)  Exercise and weight loss 
d)  Rest and relaxation techniques 
e)  An intensive insulin regimen

The correct answer is c)

Explanation:
The metabolic syndrome is a combination of obesity, lipid abnormalities,
hypertension, and hyperglycemia. It confers a high risk for cardiovascular disease.
Primary therapy includes exercise, weight loss, and dietary changes. This improves all
aspects of the metabolic syndrome, mainly as a result of decreased insulin resistance.
Antioxidants have no proven benefit. Thyroid hormone has no effect on metabolic
syndrome unless a person is hypothyroid. Intensive insulin regimens improve
glycemic control, and have no effect on other aspects of the syndrome, and may
contribute to weight gain, which adversely affects the syndrome. Rest and relaxation
may make one feel better psychologically, but are not a mainstay of treatment.

Question #138
QID: 2961
Topic: Metabolic Syndrome
Subject: Medicine

You are counseling a 45-year-old obese male regarding weight loss. The patient has
elevated triglyceride levels, low HDL levels, and stage 1 hypertension. He does not
currently take medications and would like to avoid taking medications in the future.
The patient has heard good things about low-carbohydrate diets and asks your opinion
about beginning such a plan.

A low-carbohydrate diet in a patient such as this is most likely to result in:  

a)  Increased LDL levels 

b)  Increased triglyceride levels 
c)  Increased blood pressure 
d)  Development of the metabolic syndrome 
e)  Better short-term weight loss than with traditional low-fat diets
The correct answer is e)

Explanation:
The recent public interest in low-carbohydrate diets has led to research into the
potential health benefits or risks. Emerging data are mostly encouraging, in that these
diets do not seem to cause the expected increases in blood pressure, LDL levels, or
triglyceride levels that the medical community had first assumed. In fact, these diets
seem to consistently result in more weight loss than low-fat diets, and lead to a more
significant reduction in triglyceride levels. This patient has symptoms of the
metabolic syndrome and has a higher risk of glucose intolerance or diabetes. Low-
carbohydrate diets have been shown to reduce insulin resistance at least as well as, if
not better than, traditional diet plans. More research will likely elicit any long-term
effects of these diets that are not currently known.

Question #139
QID: 3134
Topic: Metabolic Syndrome
Subject: Medicine

A 54 year old female diabetic who takes fenofibrate has the following fasting lipid
levels: total cholesterol 5.18 mmol/L (200 mg/dL), LDL cholesterol 1.66 mmol/L (64
mg/dL), HDL cholesterol 1.0 mmol/L (40 mg/dL), triglycerides 13.6 mmol/L (525
mg/dL). Her weight has increased by 3kg (7lb). She occasionally checks her blood
glucose and says it is “okay.” She admits to occasional diarrhea.

In order to improve this patient’s lipid status, the most appropriate next step is to:
a)  add ezetimibe
b)  check the patient for Celiac disease
c)  order TSH and hemoglobin A1c levels
d)  discontinue fenofibrate and prescribe rosuvastatin

The correct answer is c)

Explanation:
Poorly controlled diabetes mellitus and hypothyroidism are often associated with a
metabolic syndrome that can include a mixed dyslipidemia. Ezetimibe and
rosuvastatin will lower the LDL-cholesterol level but have little or no effect on
triglycerides. Celiac disease is not a cause of hypertriglyceridemia, but it may be
associated with malabsorption, leading to hypocholesterolemia.

Question #140
QID: 5582
Topic: Metabolic Syndrome
Subject: Medicine

A 55-year-old white male sees you for follow-up after a recent lipid panel revealed no
improvement in his hyperlipidemia. His total cholesterol level is 7.15 mmol/L, with
an LDL-cholesterol level of 4.7 mmol/L, an HDL-cholesterol level of 0.98 mmol/L,
and a triglyceride level of 7.15 mmol/L. These numbers are similar to two previous
lipid panels obtained over the last several months, despite attempts at lifestyle
changes. He has adequately treated essential hypertension, with a blood pressure of
125/83 mm Hg. There is no history of diabetes mellitus or tobacco use, and no family
history of premature coronary heart disease.

A physical examination is unremarkable except for a BMI of 33 kg/m and a waist

circumference of 107 cm (42 in). His fasting blood glucose level is 5.9 mmol/L.

After discussion with the patient, you decide to start prescription drug therapy. The
initial target of this therapy should be to reach his goal level of :
a)  LDL cholesterol
b)  HDL cholesterol
c)  non-HDL cholesterol
d)  triglycerides
e)  fasting blood glucose

The correct answer is a)

Explanation:
This patient meets the criteria for metabolic syndrome. In addition to lifestyle
changes, pharmacologic treatment for his hyperlipidemia should be considered. The
initial goal of this therapy should be to reach his LDL-cholesterol goal, usually using
a statin. After achievement of this goal, non-HDL cholesterol is the secondary target
for therapy. Non-HDL cholesterol is calculated by subtracting HDL cholesterol from
total cholesterol.

Question #141
QID: 2946
Topic: Subacute Thyroiditis
Subject: Medicine

A 40-year-old white female complains of discomfort in her anterior neck. She also
gives a history of malaise, low-grade fever, and a tender thyroid gland.

                                                                                      Laboratory Findings

                                                        WBCs……………………………………..
…............12,100/mm3 (N 4300-10.800)
                                                        Granulocytes……………………..
…........................30% (N 42-75)
                                                        
Monocytes…………………………...........................4% (N 2-9)
                                                        Lymphocytes……………………...........
…................66% (N 20-51)
                                                        Free thyroxine (FT4)…………..
………....................2.8 ng/dL (N 0.8-2.4)
                                                        Erythrocyte sedimendation rate (Westergren)......60
mm/hr (N 0-20)

Which one of the following would most likely be seen on a thyroid nuclear medicine
study?  

a)  Slightly increased uptake 

b)  Normal uptake 
c)  Markedly decreased radioactive iodine uptake 
d)  A single hot node 
e)  Multiple cold areas

The correct answer is c)

Explanation:
This patient has a clinical presentation typical of subacute thyroiditis. An elevated
erythrocyte sedimentation rate is an almost certain feature, and slight leukocytosis
may also be seen, as well as a modest degree of thyrototoxicosis and a slightly
elevated serum T4 level. A small thyroid gland would be expected on a thyroid scan.
Because the disease interferes with iodine metabolism, radioiodine uptake is
decreased. Hot, toxic nodules or a multinodular goiter would not be expected.
Generalized thyroid enlargement and increased radioactive iodine uptake would be
expected with Graves’ disease.

Question #142
QID: 3150
Topic: Subacute Thyroiditis
Subject: Medicine

A 45 year old Hispanic female presents with diffuse, tender swelling in her anterior
neck. These symptoms were preceded by a prodrome of sore throat, low-grade fever,
myalgias, and fatigue. On examination she has a tender, enlarged thyroid gland.
Laboratory tests reveal elevated free T4 and low TSH.

Which one of the following is indicated at this time to determine appropriate

treatment?  

a)  Fine-needle aspiration of the thyroid gland

b)  Radioactive iodine uptake (RAIU) at 24 hours
c)  Immediate initiation of oral prednisone, 40-60 mg/day
d)  Antibiotics that cover Streptococcus pyogenes, Staphylococcus aureus, and
Streptococcus pneumoniae
e)  A CT scan of the neck

The correct answer is b)

Explanation:
Subacute granulomatous thyroiditis is the most common cause of thyroid pain. It is
four times more common in women, most often occurs at 40-50 years of age, and is
usually attributed to a viral infection. Symptoms and signs of this disorder include a
prodrome of myalgias, pharyngitis, low-grade fever, and fatigue, followed by a
tender, diffuse goiter and neck pain that often radiates up to the ear. Hyperthyroidism
is seen in half of affected individuals, and must be differentiated from that found with
Graves’ disease to determine appropriate treatment. The hallmarks of subacute
granulomatous thyroiditis are a very high erythrocyte sedimentation rate (ESR), often
as high as 60-100, and a radioiodine uptake of less than 1% at 24 hours (whereas in
those with Graves’ disease it is elevated). Treatment consists of relieving the thyroid
pain and tenderness with NSAIDs. If no improvement occurs in a week, prednisone
may be given in a dosage of 40-60 mg/day, tapered off over 4-6 weeks.

Suppurative thyroiditis is an extremely rare form of thyroiditis caused by bacterial,

fungal, mycobacterial, or parasitic infection of the thyroid gland. Predisposing factors
include congenital abnormalities such as persistent thyroglossal duct or piriform sinus
fistula, greater age, and immunosuppression. Patients commonly present with acute
unilateral anterior neck pain and erythema of the skin overlying an exquisitely tender
thyroid. Fever, dysphagia, and dysphonia are also present. Thyroid function most
often is normal, but hyper- or hypothyroidism may be present. The erythrocyte
sedimentation rate is elevated, and the WBC count shows a marked increase with a
left shift. Fine-needle aspiration with a Gram stain and culture is the most useful
diagnostic test.

Question #143
QID: 6152
Topic: Subacute Thyroiditis
Subject: Medicine

A 45-year-old female had myalgias, a sore throat, and a fever 2 weeks ago. She now
has anterior neck tenderness and swelling, with pain radiating up to her ears. An
examination reveals a tender goiter.

Which one of the following would support a diagnosis of subacute granulomatous

thyroiditis?
a)  Pretibial myxedema
b)  Exophthalmos
c)  A thyroid bruit
d)  Low radioactive iodine uptake (<5%)
The correct answer is d)

Explanation:
Subacute granulomatous thyroiditis is the most common cause of thyroid pain. Free T4
is elevated early in the disease, as it is in Graves’ disease; however, later in the
disease T4 becomes depressed and then returns to normal as the disease resolves.
Pretibial myxedema, exophthalmos, and a thyroid thrill or bruit can all be found in
Graves’ disease, but not in subacute granulomatous thyroiditis. Patients with subacute
granulomatous thyroiditis will have a low radioactive iodine uptake (RAIU) at 24
hours, but patients with Graves’ disease will have an elevated RAIU.

Question #144
QID: 3243
Topic: Hyperandrogenism
Subject: Medicine

Which one of the following is the most common cause of hyperandrogenism in

women?

a)  Acromegaly
b)  Carcinoma of the ovary
c)  Congenital adrenal hyperplasia
d)  Cushing’s syndrome
e)  Polycystic ovary syndrome

The correct answer is e)

Explanation:
Hyperandrogenism is caused by polycystic ovary syndrome in at least 75% of cases.
This diagnosis is made when there is otherwise unexplained chronic
hyperandrogenism and oligo-ovulation or anovulation. Women with polycystic ovary
syndrome should also be evaluated for glucose intolerance and the metabolic
syndrome.

Congenital adrenal hyperplasia is present in 2% of women with hyperandrogenism;

androgen-secreting tumors are seen in 0.2%, with more than half being malignant.
Cushing’s syndrome and acromegaly are other infrequent causes of androgen excess.

Question #145
QID: 3283
Topic: Hypomagnesemia
Subject: Medicine

A 58-year-old male, previously hospitalized because of weakness, is found to have

severe hypokalemia. His urinary electrolytes show significant potassium wasting.
This combination of findings suggests the patient also has a significant deficiency of:  

a)  Aldosterone
b)  Magnesium
c)  Sodium
d)  Hydrogen ions
e)  Calcium

The correct answer is b)

Explanation:
Approximately half of hospitalized patients in whom serum electrolytes are ordered
have unrecognized hypomagnesemia. Many of these patients have hypokalemia
and/or hypocalcemia. Hypomagnesemia also causes renal potassium wasting, which is
refractory to potassium replacement until magnesium is replaced.

Question #146
QID: 3320
Topic: Glycemic Index
Subject: Medicine

Food with a higher glycemic index:  

a)  releases carbohydrates into the bloodstream as glucose more rapidly

b)  induces a slower insulin response
c)  is less likely to lead to reactive hypoglycemia
d)  is less likely to lead to metabolic syndrome
e)  leads to lower levels of circulating insulin

The correct answer is a)

Explanation:
The higher the glycemic index of a food, the more rapidly its carbohydrates are
released into the bloodstream as glucose. Foods with a high glycemic index induce a
more rapid insulin response, are more likely to lead to reactive hypoglycemia and a
metabolic syndrome, and lead to higher levels of circulating insulin.

Question #147
QID: 5886
Topic: Conn's Disease
Subject: Medicine

 A 34 year old man is found to have a blood pressure of 180/105 mmHg. He admits to stress at work
and states that his father was diagnosed as hypertensive at the age of 60 but, thus far, has not required
treatment. He denies taking any medications. He smokes 25 cigarettes per day but takes no alcohol. On
physical examination he is not obese, has no signs of cardiovascular disease, and no hypertensive
retinopathy. The results of investigations are given below:

Urine analysis negative, Na 146 mmol/L, K 2.8 mmol/L, Cl 102 mmol/L, HCO3 33 mmol/L, Urea 4.2
mmol/L, Creatinine 92 mmol/L, Glucose 6.2 mmol/L

What is the most likely explanation for his hypokalemia?

a)   Increased urinary losses of potassium
b)   Reduced dietary intake
c)   Surreptitious laxative abuse
d)   Metabolic alkalosis

The correct answer is a)

Explanation:
In primary hyperaldosteronism (Conn’s disease), overproduction of aldosterone leads
to fluid retention and increased blood pressure, weakness, and, rarely, periods of
paralysis. Hyperaldosteronism can be caused by a tumor in the adrenal gland or may
be a response to some diseases. High aldosterone levels can cause high blood pressure
and low potassium levels; low potassium levels may cause weakness, tingling, muscle
spasms, and periods of temporary paralysis. Doctors measure the levels of sodium,
potassium, and aldosterone in the blood. Sometimes, a tumor is removed, or people
take drugs that block the action of aldosterone.

Aldosterone, a hormone produced and secreted by the adrenal glands, signals the
kidneys to excrete less sodium and more potassium. Aldosterone production is
regulated partly by corticotropin (secreted by the pituitary gland) and partly through
the renin-angiotensin-aldosterone system.
Hyperaldosteronism can be caused by a tumor (usually a noncancerous adenoma) in
the adrenal gland (a condition called Conn's syndrome), although sometimes both
glands are involved and are overactive.

Question #148
QID: 8709
Topic: Androgen Insensitivity Syndrome
Subject: Medicine

All of the following features have been described in women with androgen
insensitivity syndrome, except:

a)  Mammary aplasia
b)  Female phenotype
c)  Absence of wolffian duct structures
d)  Short vagina
e)  Absence of mullerian duct structures

The correct answer is a)

Explanation:
Androgen insensitivity syndrome (AIS) is when a person who is genetically male (has
one X and one Y chromosome) is resistant to male hormones called androgens. As a
result, the person has some or all of the physical characteristics of a woman, despite
having the genetic makeup of a man.

In its classic form (complete androgen resistance), the person appears to be female but
has no uterus, and has sparse armpit and pubic hair. At puberty, female secondary sex
characteristics (e.g., breasts) develop, but menstruation and fertility do not.

Incomplete AIS, however, is often discovered during childhood because a person may
have both male and female physical characteristics. Many have partial fusion of the
outer vaginal lips, an enlarged clitoris, and a short, blind-ending vagina.

The Müllerian ducts will develop to form the fallopian tubes, uterus, and the upper
portion of the vagina. The Wolffian duct develops into a system of connected organs
between the testis and the prostate, the epididymis, the vas deferens, the seminal
vesicle, and the prostate. Both of these ducts will be absent in AIS.

Question #149
QID: 8711
Topic: Androgen Insensitivity Syndrome
Subject: Medicine

With respect to androgen insensitivity syndrome, which of the following is true?

a)  Genotype is XY
b)  Lack of breast development and absence of uterus
c)  Serum testosterone is below normal male range
d)  Secondary sex characteristics are male
e)  The condition is autosomal recessive

The correct answer is a)

Explanation:
Androgen insensitivity syndrome (AIS) is when a person who is genetically male (has
one X and one Y chromosome) is resistant to androgens. As a result, the person has
some or all of the physical characteristics of a woman, despite having the genetic
makeup of a man.

In its classic form (complete androgen resistance), the person appears to be female but
has no uterus, and has sparse armpit and pubic hair. At puberty, female secondary sex
characteristics (e.g., breasts) develop, but menstruation and fertility do not.

Incomplete AIS, however, is often discovered during childhood because a person may
have both male and female physical characteristics. Many have partial fusion of the
outer vaginal lips, an enlarged clitoris, and a short, blind-ending vagina.

The individual is often diagnosed because of ambiguous genitalia. Sometimes,

though, the person has primarily male characteristics and the only symptom is a low
sperm count as an adult, perhaps with breast enlargement.

Question #150
QID: 8710
Topic: Secondary Amenorrhea
Subject: Medicine

Causes of secondary (not primary) amenorrhea include:

a)  Turner syndrome
b)  Anorexia
c)  Androgen insensitivity syndrome
d)  Gonadal dysgenesis
e)  Imperforate hymen

The correct answer is b)

Explanation:
Secondary amenorrhea is the absence of menstrual periods for 6 months in a woman
who had previously been regular, or for 12 months in a woman who had irregular
periods. This problem is seen in about 1% of women of reproductive age.

Primary amenorrhea is when the woman has never had a period in her life. This page
will not discuss primary amenorrhea which is rare. The causes of primary amenorrhea
are also quite different from secondary amenorrhea.

Secondary amenorrhea can be caused by hyperprolactinemia., certain medications

such as phenothiazines (used for psychiatric disorders), anorexia nervosa, cushing's
disease, hypothyroidism, sheehan's syndrome and asherman's syndrome.

Question #151
QID: 8736
Topic: Human Chorionic Gonadotropin
Subject: Medicine

Increased human chorionic gonadotropin (hCG), in the absence of pregnancy, may

suggest which one of the following?
a)  Carcinoma of the cervix
b)  Uterine choriocarcinoma
c)  Carcinoma of the uterine corpus
d)  Granulosa cell tumor of the ovary
e)  Leiomyoma

The correct answer is b)

Explanation:
Gestational trophoblastic disease like Hydatidiform moles ("molar pregnancy") or
Choriocarcinoma may produce high levels of ßhCG (due to the presence of
syncytialtrophoblasts- part of the villi that make up the placenta) despite the absence
of an embryo. This, as well as several other conditions (seminoma, germ cell tumors,
teratoma with elements of choriocarcinoma (this is rare), and islet cell tumor), can
lead to elevated hCG readings in the absence of pregnancy.

Question #152
QID: 10349
Topic: Euthyroid Sick Syndrome
Subject: Medicine

A 62-year-old male is admitted to the hospital for urosepsis. His medical history is
significant only for hypertension. On examination he has a temperature of 36.5°C
(97.7°F), a TSH level of 0.2 ₃U/mL (N 0.4-5.0), and a free T4 level of 0.4 ng/dL (N
0.6-1.5).

Which one of the following is the most likely explanation for these findings?

a)  Pituitary adenoma
b)  Graves’ disease
c)  Subacute thyroiditis
d)  Subclinical hypothyroidism
e)  Euthyroid sick syndrome

The correct answer is e)

Explanation:
The euthyroid sick syndrome refers to alterations in thyroid function tests seen
frequently in hospitalized patients, and decreased thyroid function tests may be seen
early in sepsis. These changes are statistically much more likely to be secondary to
the euthyroid sick syndrome than to unrecognized pituitary or hypothalamic disease.
Graves’ disease generally is a hyperthyroid condition associated with low TSH and
elevated free T4. Subclinical hypothyroidism is diagnosed by high TSH and normal
free T 4 levels.
Subacute thyroiditis most often is a hyperthyroid condition.

Question #153
QID: 11056
Topic: Euthyroid Sick Syndrome
Subject: Medicine

An inpatient with multiple injuries sustained in car accident felt cold last night and
was seen by a family medicine resident who among other investigations ordered
thyroid function tests, which showed low serum total and free T3 level, normal total
and free T4, and normal TSH level.
Which one of the following management options would be best for this patient?

a)  Start injection of liothyronine (T3) 10µg every 12 hours, immediately

b)  Prescribe thyroxine (T4) at 50 µg per day, immediately
c)  Order radioiodine uptake and thyroid scan
d)  Order serum thyroglobulin level
e)  Observe and monitor during recovery

The correct answer is e)

Explanation:
Low serum T3 with normal T4 and TSH in patients with severe diseases or trauma is
the most common presentation of the sick euthyroid syndrome. In this syndrome,
thyroid function is normal (euthyroid) as indicated by normal serum TSH. These
patients need no more than observation and monitoring during recovery (choice E).
Indeed, without strong suspicion of thyroid disorders, it is not advisable to perform
thyroid function tests in patients with acute severe diseases or trauma.

> Starting injection of liothyronine (choice A) or thyroxine (choice B) are not the
correct choices. In the absence of history or physical signs suggestive of
hypothyroidism, it is not advisable to give thyroid hormone replacement therapy.
Indeed, according to some reports, thyroid hormone replacement therapy might
worsen the outcome of the diseases causing sick euthyroid syndrome.
> Ordering radioiodine uptake and thyroid scan (choice C) or serum thyroglobulin
level (choice D) are not the correct choices. In the absence of history or physical signs
suggestive of thyroid disease together with the thyroid hormone profile typical of sick
euthyroid syndrome, no further investigation is required.

Key point:
Severe acute disease or trauma may lead to abnormalities of serum thyroid hormone
profile. These disturbance, however, usually resolve spontaneously when patients
recover from the acute disease or trauma.

Question #154
QID: 10831
Topic: Aspartame metabolism
Subject: Medicine

 Use of the artificial sweetener aspartame (NutraSweet) is contraindicated in patients

who have:

a)   Galactosemia
b)   Homocystinuria
c)  Orotic aciduria 
d)   Phenylketonuria

The correct answer is d)

Explanation:
 Aspartame is completely hydrolyzed in the gut to methanol, aspartic acid, and
phenylalanine, and is therefore contraindicated in patients with phenylketonuria.

Question #155
QID: 10951
Topic: Multiple endocrine neoplasia
Subject: Medicine

A 35-year-old male presents to your department with severe abdominal pain. He had
similar complaints 3 months ago and after evaluation he was prescribed omeprazole
for peptic ulcer disease. He says that the drug seemed to help a bit initially, but
currently he feels his pain is getting worse. He says that the pain is associated with
food. His father died at the age of 51 in a car accident. His mother is 58 years old and
healthy. He has an older brother with a history of kidney stones. On physical
examination he has pain in the epigastric region. Laboratory tests show:

Sodium: 140 mmol/L

Chloride: 116 mmol/L
Potassium: 4.8 mmol/L
Bicarbonate: 19 mmol/L
Magnesium: 0.85 mmol/L
Calcium: 3 mmol/L
BUN: 7 mmol/L
Creatinine: 200 microg/L
Glucose: 5.5 mmol/L
Gastrin: 1.1 ng/mL (normal < 100pg/mL)

If MEN is suspected, which of the following would be the best choice to arrive at the
correct diagnosis?

a)  Abdominal CT scan
b)  Endoscopic ultrasound with biopsy
c)  24-hour urine vanillylmandelic acid
d)  Head MRI
e)  Serum calcitonin

The correct answer is d)

Explanation:
This patient’s abdominal pain is most likely caused by peptic ulcer disease. His
history of abdominal pain, minimal relief with omeprazole, and the laboratory test
results that reveal excessive levels of gastrin point to a gastrinoma (i.e.Zollinger-
Ellison syndrome) as the most likely cause. This patient also has elevated levels of
calcium and a family history of nephrolithiasis, which are suggestive of
hyperparathyroidism. When all of this is taken into account, we must suspect multiple
endocrine neoplasia type I (MEN I). This condition is a constellation of pituitary
adenomas, parathyroid tumors, and pancreatic islet cell tumors. 
Pituitary adenomas secrete prolactin in 25% of patients and growth hormone in 5% of
patients. Large pituitary adenomas may cause bitemporal hemianopsia, which is a risk
factor for motor vehicle accidents in these patients. Head MRI (choice D) is
considered the screening test of choice for pituitary adenomas.

> Abdominal CT scan (choice A) in the study of Zollinger-Ellison syndrome is used

in the staging of cancer lesion. At this point, it would not be the best next step.
> Endoscopic ultrasound with biopsy (choice B) is an invasive study that should not
be considered as the next step in the evaluation of this patient. Somatostatin receptor
scintigraphy would be the best next step in the evaluation of Zollinger-Ellison
syndrome but it was not among the choices offered.
> 24-hour urine vanillylmandelic acid (choice C) is useful in evaluating patients
suspected of pheochromocytoma. This would be considered in a patient suspected of
MEN II. MEN II a is a constellation of pheochromocytoma, parathyroid neoplasia,
and medullary carcinoma of the thyroid, while MEN IIb includes pheochromocytoma,
medullary thyroid carcinoma, and intestinal neuromas.
> Serum calcitonin (choice E) is also useful in the evaluation of medullary carcinoma
of the thyroid in patients with MEN II.

Key point:
Multiple endocrine neoplasia type I is a constellation of pituitary adenomas,
parathyroid tumors, and pancreatic islet cell tumors. In a patient who presents with
Zollinger-Ellison syndrome and hypercalcemia, a head MRI is indicated to screen the
patient for pituitary adenoma.

Question #156
QID: 2904
Topic: Hyperglycemia
Subject: Medicine

A 73-year-old female began vomiting yesterday after undergoing bronchoscopy. This

morning she is still vomiting. Her husband brings her to the emergency department
because she is obviously uncomfortable and can’t keep any fluid down. On
examination she is delirious.

                                                                                       Laboratory Findings

                                                         Sodium………………………………………140
mmol/L (N 135-145)
                                                         Potassium……………………………………5.7
mmol/L (N 3.5-4.5)
                                                         BUN……………………..……………………65
mg/dL (N 12-20)
                                                         Serum creatinine…………...……………….3.2
mg/dL (N 0.6-1.1)
                                                         Serum glucose……………………....………36.1
mmol/L

Which of the following is indicated as the first line of management of this patient?
a)  Immediate intravenous insulin infusion 
b)  Oral hypoglycemic agents and training in home glucose testing technique 
c)  Potassium may be added to the infusion fluid
d)  Insulin glargine (Lantus) and insulin lispro (Humalog) 
e)   Vigorously rehydration with isotonic sodium chloride solution

The correct answer is e)

Explanation:
The patient is in a hyperosmolar, hyperglycemic state (HHS) which is characterized
by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis.
Most patients present with severe dehydration and focal or global neurologic deficits.

Rapid and aggressive intravascular volume replacement is always indicated as the

first line of therapy for patients with HHS. Isotonic sodium chloride solution is the
fluid of choice for initial treatment because sodium and water must be replaced in
these severely dehydrated patients.

This patient should be treated with intravenous fluids and an insulin infusion in an
intensive-care setting, with hourly follow-up of blood glucose levels. Insulin used
without concomitant vigorous fluid replacement increases the risk of shock. Although
she has renal insufficiency and hyperkalemia, the hyperkalemia will resolve with
insulin and fluid infusion. In fact, potassium supplementation will be needed within a
few hours. The delirium will usually clear with correction of the metabolic
abnormalities. Oral diabetic agents or a subcutaneous insulin protocol will be needed
for long-term control, but are not aggressive enough to manage this patient’s acute
problem.

Question #157
QID: 11049
Topic: Acromegaly complication
Subject: Medicine

A 45-year-old woman, diagnosed with Acromegaly comes to your practice for a

follow up visit. She says she has been feeling fine since her last visit, except for pain
in both knees, which has been limiting her activity in the past few weeks.

Which of the following is a particularly common cause of joint pain in a patient with
Acromegaly?

a)   Osteoarthritis
b)   Overweight
c)   Rheumatoid arthritis
d)   Iron deposits
e)  Gout

The correct answer is a)

Explanation:
The excessive secretion of growth hormone (GH) along with IGF-1 stimulates the
proliferation of cartilage, periarticular connective tissue, and bone, resulting in several
musculoskeletal problems in patients with acromegaly. Even though the options
mentioned could be present in this patient, patients with acromegaly are especially
prone to osteoarthritis (choice A), most often affecting the knees, shoulders, hips and
hands, affecting single or multiple joints.
Hypertrophy of the cartilage initially produces widening of the joint space when seen
on an X-ray. This new cartilage is more susceptible to fissuring, ulceration and
destruction, than normal cartilage. As the degradation of the cartilage progresses, the
joint space narrows, subchondral sclerosis appears, and ultimately, osteophytes are
formed.

> All of the answers are possible causes of this patient's knee pain, yet the most
common is osteoarthritis.