Thyroid
Diabetes
Parathyroid
Wildcard
100
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)
What is B. Lithium
100
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 200 mg/dL. His serum creatinine level is 1.9 mg/dL. 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 patients regimen to treat his diabetes mellitus? A. The American Diabetes Association 1800-calorie/day diet B. Metformin (Glucophage) C. Pioglitazone (Actos) D. Exenatide (Byetta) E. Insulin glargine (Lantus)
What is E. Insulin glargine (Lantus)
100
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? (check one) 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
What is D. Serum parathyroid hormone
100
In evaluating an adult with anemia, which one of the following findings most reliably indicates a diagnosis of iron deficiency anemia? (check one) A. Low total iron-binding capacity B. Low serum iron C. Low serum ferritin D. Microcytosis E. Hypochromia The total iron-binding capacity is elevated, not decreased, in iron deficiency anemia. As an acute-phase reactant, serum iron may be decreased in response to inflammation even when total body stores of iron are not decreased. Microcytosis and hypochromia are both features of iron deficiency anemia occurring late in its development, but both can also be seen in the thalassemias. Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin, however, is diagnostic for iron deficiency even in its early stages.
What is C. Low serum ferritin The total iron-binding capacity is elevated, not decreased, in iron deficiency anemia. As an acute-phase reactant, serum iron may be decreased in response to inflammation even when total body stores of iron are not decreased. Microcytosis and hypochromia are both features of iron deficiency anemia occurring late in its development, but both can also be seen in the thalassemias. Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin, however, is diagnostic for iron deficiency even in its early stages.
200
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 µU/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
What is D. Elevated LDL cholesterol
200
Which one of the following medications should be discontinued in a patient with diabetic gastroparesis? (check one) A. Exenatide (Byetta) B. Benazepril (Lotensin) C. Metformin (Glucophage) D. Hydrochlorothiazide E. Prochlorperazine maleate
What is A. Exenatide (Byetta)
200
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? (check one) A. Radiographs of the hands B. An osteocalcin level C. An intact parathyroid hormone (PTH) level D. A 25-OH Vitamin D level
What is C. An intact parathyroid hormone (PTH) level 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.
200
Which one of the following is a cause of thyrotoxicosis characterized by a decreased radioactive iodine uptake? (check one) A. Graves’ disease B. Subacute thyroiditis C. Toxic multinodular goiter D. Solitary toxic thyroid nodule
What is B. Subacute thyroiditis Thyrotoxicosis with a high 24-hour 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 lymphocytic thyroiditis, radiation-induced thyroiditis, iodine-induced thyroiditis, thyrotoxicosis factitia, metastatic follicular thyroid cancer, and struma ovarii.
300
A 70-year-old white female comes to your office for an initial visit. She has taken levothyroxine (Synthroid), 0.3 mg/day, for the last 20 years. Although a recent screening TSH was fully suppressed at <0.1 µU/mL, she claims that she has felt “awful” when previous physicians have attempted to lower her dosage. You explain that a serious potential complication of her current thyroid medication is: A. Adrenal insufficiency B. Carcinoma of the ovary C. Carcinoma of the thyroid D. Hip fracture E. Renal failure
What is D. Hip fracture Women older than 65 years of age who have low serum TSH levels, indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels are normal.
300
At a routine visit, a 50-year-old white female with a 10-year history of type 2 diabetes mellitus has a blood pressure of 145/90 mm Hg and significant microalbuminuria. Which one of the following would be an absolute contraindication to use of an ACE inhibitor in this patient? (check one) A. A previous history of angioneurotic edema B. Stage IV or V chronic kidney disease C. A history of hyperkalemia D. A history of recent myocardial infarction E. A cardiac ejection fraction <25% Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. Elevated creatinine levels are not an absolute contraindication to ACE inhibitor therapy. Myocardial infarction and a reduced cardiac ejection fraction are indications for ACE inhibitor therapy. ACE inhibitors do not affect asthma. Ref: Bicket DP: Using ACE inhibitors appropriately. Am Fam Physician 2002;66(3):461-468, 473.
What is A. A previous history of angioneurotic edema Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. Elevated creatinine levels are not an absolute contraindication to ACE inhibitor therapy. Myocardial infarction and a reduced cardiac ejection fraction are indications for ACE inhibitor therapy.
300
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 11.2 mg/dL (N 8.4-10.2) and an intact 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
What is A. Lithium
300
In a patient with HIV infection, the threshold for initiating treatment for tuberculosis after PPD screening is induration greater than or equal to: (check one) A. 2.5 mm B. 5.0 mm C. 7.5 mm D. 10 mm E. 15 mm
What is B. 5.0 mm
400
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
What is C. Order a free T4 level
400
U.S. Department of Transportation standards for commercial drivers would disqualify which one of the following? (check one) A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8–6.4) B. A 50-year-old female with uncorrected 20/40 vision in both eyes C. A 57-year-old male who had an inferior myocardial infarction 3 years ago and had a recent negative treadmill test D. A 64-year-old male who fails a whispered-voice test in one ear
What is A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8–6.4) Insulin-dependent diabetes, even if well controlled, disqualifies a driver for commercial interstate driving. Vision of 20/40 is the minimum allowed under Department of Transportation regulations. Adequate hearing in one ear and well-compensated controlled heart disease are both allowed. Blood pressure of 160/90 mm Hg or less merits an unrestricted 2-year certification. Drivers with a blood pressure of 160/90–181/105 mm Hg can receive a 3-month temporary certification during which treatment for hypertension should be undertaken. Ref: Pommerenke F, Hegmann K, Hartenbaum NP: DOT examinations: Practical aspects and regulatory review. Am Fam Physician 1998;58(2):415-426. 2) U.S. Department of Transportation: Federal motor carrier safety regulations, rules and notices, 2004. Available at www.fmcsa.dot.gov/rulesregs/fmcsrhome.htm.
400
Routine blood tests frequently reveal elevated calcium levels. When this elevation 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
What is B. Kidney stones 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.
400
Which one of the following can contribute to serum calcium elevation? (check one) A. Furosemide (Lasix) B. Verapamil (Calan, Isoptin) C. Enalapril (Vasotec) D. Hydrochlorothiazide E. Allopurinol (Zyloprim)
What is D. Hydrochlorothiazide 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 reabsorption. 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.
500
There are currently 3 different labs that can diagnose diabetes mellitus type 2. What are they and what are there cut-off points to meet diagnostic criteria?
What is: 1. bA1c levels ≥6.5%, when testing is performed by a laboratory method certified by the National Glycohemoglobin Standardization Program and standardized to the Diabetes Control and Complications Trial assay. 2. a fasting plasma glucose level of ≥126 mg/dL, 3. a 2-hour plasma glucose level ≥200 mg/dL during an oral glucose tolerance test, and a random plasma glucose level of ≥200 mg/dL in patients with symptoms of hyperglycemia or a hyperglycemic crisis.
500
Hemoglobin A1c assays are INACCURATE in patients with: A. Secondary hypertension B. AIDS C. Cor pulmonale D. Sickle cell disease E. Polycythemia vera 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.
What is D. Sickle cell disease 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.
500
This hormone is abnormal with chronic renal insufficiency. What is (part one) high vs low, (part two) name the hormone.
What is elevated Intact PTH?
500
A small child with failure to thrive is found to have a bone age that is markedly delayed relative to height age and chronologic age. The most likely etiology is: (check one) A. Cystic fibrosis B. Hypothyroidism C. Down syndrome D. Fetal alcohol syndrome E. Gonadal dysgenesis
What is B. Hypothyroidism Hypothyroidism is associated with markedly delayed bone age relative to height age and chronologic age. In cystic fibrosis, bone age and height age are equivalent, but both lag behind chronologic age. Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a height age which is delayed relative to bone age. This pattern is also seen as a result of maternal substance abuse.
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