A
B
C
D
100
An 81-year-old man is evaluated for a 3-month history of fatigue, constipation, cognitive symptoms, and cold intolerance. He has gained 4.5 kg (10.0 lb) during the past year. Medical history is significant for coronary artery disease. Medications are rosuvastatin, lisinopril, metoprolol, and aspirin.
On physical examination, pulse rate is 54/min. Weight is 65 kg (143.0 lb). The thyroid is firm but not enlarged, the skin is cool and dry, and his hair is coarse. Deep tendon reflexes are delayed.
Laboratory studies show a thyroid-stimulating hormone level of 25 µU/mL (25 mU/L) and free thyroxine level of 0.5 ng/dL (6.5 pmol/L).
Which of the following is the most appropriate treatment?
Levothyroxine, 25 μg/d
Levothyroxine, 100 μg/d
Thyroid, desiccated, 60 mg/d
Triiodothyronine, 50 μg/d
100
A 38-year-old-woman is evaluated for a 9-month history of oligomenorrhea, a deepening voice, and increased body hair. Her last menses was 3 months ago. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. She has frontal hair loss and coarse dark hairs on her chin and chest. Larynx appears larger than normal. Clitoromegaly is present on pelvic examination.
Laboratory studies show a negative pregnancy test, a dehydroepiandrosterone sulfate level of 910 μg/dL (24.7 μmol/L), and a total testosterone level of 97 ng/dL (3.4 nmol/L).
Which of the following is the most appropriate diagnostic test to perform next?
Abdominal CT
Adrenal vein sampling
Ovarian vein samplingD
Pelvic ultrasonography
Pituitary MRI
100
A 73-year-old woman is evaluated in the emergency department after 2 days of weakness, headache, and nausea. She underwent uncomplicated transsphenoidal resection of a pituitary macroadenoma 6 days ago and was discharged from the hospital 3 days ago.
On physical examination, vital signs are normal. No orthostasis and no neurologic or visual deficits are present. Her mucous membranes are moist.
Laboratory studies show a serum sodium level of 128 mEq/L (128 mmol/L), thyroid-stimulating hormone level of 0.9 μU/mL (0.9 mU/L), and free thyroxine level of 1.1 ng/dL (14.2 pmol/L). Before discharge, her 8 AM serum cortisol level was 15 μg/dL (414 nmol/L), and a random serum cortisol level taken at 3 PM was 10 μg/dL (276 nmol/L).
Which of the following is the most likely diagnosis?
Adrenal insufficiency
Dehydration
Secondary hypothyroidism
Syndrome of inappropriate antidiuretic hormone secretion
100
A 58-year-old woman is evaluated for further management of type 2 diabetes mellitus after hospital discharge. She was hospitalized with a myocardial infarction and subsequent coronary stenting, and her hospital course was complicated by heart failure. Her hemoglobin A1c level was 8.2% while hospitalized. Hyperglycemia was treated with insulin. Her medical history is significant for hypertension, dyslipidemia, obesity, and idiopathic pancreatitis. Medications are metformin, lisinopril, carvedilol, atorvastatin, furosemide, aspirin, and clopidogrel.
On physical examination, vital signs are normal. BMI is 29.
Laboratory studies show an estimated glomerular filtration rate of 52 mL/min/1.73 m2 and blood glucose level of 202 mg/dL (11.2 mmol/L).
Which of the following is the best additional treatment for diabetes mellitus?
Empagliflozin
Glipizide
Liraglutide
Pioglitazone
200
A 55-year-old man is evaluated for a 1-year history of decreased libido, erectile dysfunction, and fatigue. Medical history is also significant for opioid use disorder treated with methadone. He takes no other medications.
On physical examination, vital signs are normal. BMI is 25. The remainder of the examination, including genital and prostate examination, is normal.
A morning testosterone level obtained 4 weeks ago is low.
Pituitary MRI is normal.
Laboratory studies:
Hemoglobin
Normal
Follicle-stimulating hormone
2.1 mU/mL (2.1 U/L)
Luteinizing hormone
1.4 mU/mL (1.4 U/L)
Prolactin
18 ng/mL (18 μg/L)
Testosterone, total (8 AM) (second measurement)
140 ng/dL (4.9 nmol/L)
Which of the following is the most appropriate treatment?
Alprostadil
Cabergoline
Sildenafil
Testosterone
200
A 20-year-old woman is evaluated for a several-month history of unintentional weight loss, diarrhea, poor glycemic control, and pruritic rash. She was diagnosed with type 1 diabetes mellitus 2 years ago. Medications are insulin glargine and insulin aspart injection.
On physical examination, vital signs are normal. BMI is 20. A rash is symmetrically distributed over her knees, elbows, sacrum, and buttocks. A representative sample of the rash is shown. No abdominal tenderness is noted. The remainder of the examination is normal.
Which of the following is the most appropriate diagnostic test to perform next?
Colonoscopy
Gastric emptying study
IgA tissue transglutaminase antibody measurement
Thyroid peroxidase antibody measurement
200
A 22-year-old woman is evaluated in the office for a 6-month history of intermittent nausea, anorexia, and occasional constipation. She does not smoke cigarettes, drink alcohol, or use recreational drugs. She otherwise feels well and takes no medications. Family history is unremarkable.
Vital signs and physical examination are normal.
Hypercalcemia was noted on an initial metabolic profile.
Repeat laboratory studies:
Calcium
11.1 mg/dL (2.8 mmol/L)
Creatinine
1.0 mg/dL (88.4 μmol/L)
Phosphorus
4.4 mg/dL (1.4 mmol/L)
Parathyroid hormone
<10 pg/mL (<10 ng/L)
25-Hydroxyvitamin D
36 ng/mL (89.9 mmol/L)
1,25-Dihydroxyvitamin D
97 pg/mL (233.0 pmol/L)
24-Hour urine calcium
450 mg/24 h
Which of the following is the most appropriate additional test?
Chest radiography
Neck ultrasonography
Parathyroid hormone-related protein
measurementDUrine calcium-creatinine ratio determination
200
A 46-year-old woman is evaluated for a 1-year history of progressive diffuse pain in the legs that worsens with weight bearing. She also reports two episodes of acute chest pain after bending followed by chest soreness lasting weeks. She has generalized muscle weakness, a waddling gait, weight loss, and postprandial bloating. She describes no other medical concerns and takes no medications or supplements.
On physical examination, the chest and abdomen are tender to palpation over the ribs bilaterally. The remainder of the physical examination is normal.
Laboratory studies:
Alkaline phosphatase
190 U/L
Calcium
7.8 mg/dL (2.0 mmol/L)
Creatinine
0.8 mg/dL (70.7 μmol/L)
Phosphorus
2.4 mg/dL (0.78 mmol/L)
A right rib radiograph shows unhealed rib fractures corresponding to the region of chest soreness. Whole-body bone scan shows increased uptake of technetium throughout the skeleton and foci of intense uptake in the ribs and pubic rami bilaterally.
Which of the following is the most likely diagnosis?
Bone metastases
Osteomalacia
Osteonecrosis
Osteoporosis
300
A 52-year-old man with type 2 diabetes mellitus is evaluated after hospitalization for a non-ST-elevation myocardial infarction. He is currently asymptomatic. Medications are metformin, aspirin, ticagrelor, atorvastatin, metoprolol, and lisinopril.
On physical examination, vital signs are normal. BMI is 28. The general physical examination is normal.
Laboratory studies show a hemoglobin A1c level of 7.0%.
Which of the following is the most appropriate treatment?
Empagliflozin
Glipizide
Pramlintide
Sitagliptin
300
A 33-year-old man is evaluated for tremulousness, nausea and vomiting, palpitations, dyspnea on exertion, and a 6.8-kg (15.0-lb) weight loss during the past month. His medical history is significant for Graves disease diagnosed 3 months ago that was controlled on methimazole and propranolol. He stopped taking the methimazole 1 month ago.
On physical examination, temperature is 39.4 °C (103.0 °F), blood pressure is 80/50 mm Hg, pulse rate is 135/min and irregular, respiration rate is 28/min, and oxygen saturation is 93% breathing ambient air. Cardiac examination reveals a rapid irregular rhythm, jugular venous distention, and bilateral pulmonary crackles.
Thyroid-stimulating hormone level is less than 0.01 μU/mL (<0.01 mU/L) and free thyroxine (T4) level is 10.0 ng/dL (129.0 pmol/L).
Chest radiograph shows pulmonary congestion. ECG reveals atrial fibrillation.
Which of the following is the most appropriate immediate management?
ICU admission
Methimazole and propranolol reinitiation
Supersaturated potassium iodine administration
Thyroidectomy
300
A 66-year-old man is evaluated for management of type 2 diabetes mellitus, diagnosed 6 years ago. For the past 4 months, he has had fatigue and unsteadiness while walking. Medications are metformin and glipizide, which he has been taking since his diagnosis.
On physical examination, vital signs are normal. BMI is 28. He has decreased vibratory sense in the great toes and loss of patellar and Achilles reflexes. The remainder of the examination is normal.
Laboratory studies:
Hemoglobin A1c
7.4%
Mean corpuscular volume
115 fL
Hematocrit
35%
Creatinine
1.3 mg/dL (115 μmol/L)
Which of the following is the most appropriate diagnostic test?
Electromyelography and nerve conduction studies
MRI of the spine
Serum vitamin B6 measurement
Serum vitamin B12 measurement
300
A 45-year-old woman is evaluated for management of obesity and type 2 diabetes mellitus diagnosed 1 year ago. During the past 6 months, she has implemented lifestyle modifications, including a low-calorie diet, weight-loss group meetings, and exercise. She has achieved a 5.0-kg (11.0-lb) weight loss. Medical history is significant for recurrent urinary tract infections. Her only medication is metformin, 850 mg twice daily.
Vital signs and physical examination findings are unremarkable. BMI is 35.
Laboratory studies show a hemoglobin A1c level of 7.6%.
Which of the following medication changes would most benefit this patient?
Add dapagliflozin
Add glimepiride
Add liraglutide
Increase metformin dosage
400
A 32-year-old woman is evaluated for a 3-month history of galactorrhea, fatigue, constipation, and weight gain of 3.6 kg (8.0 lb). With the onset of galactorrhea, her menstrual periods have become irregular and associated with excessive bleeding. Her most recent menstrual period was 5 weeks ago. She has no other medical concerns and takes no medications.
On physical examination, vital signs are normal. BMI is 28. Spontaneous galactorrhea is present. Visual fields are intact. Deep tendon reflexes are delayed. The remainder of her physical examination is normal.
Human chorionic gonadotropin testing is negative. Serum prolactin level is 68 ng/mL (68 μg/L).
Which of the following is the most appropriate management?
Cabergoline therapy
Estrogen and progesterone therapy
Pituitary MRI
Thyroid-stimulating hormone measurement
400
A 20-year-old transgender male (genetic female, identifies as male) is evaluated 3 months after starting intramuscular testosterone injections. He was previously diagnosed with gender dysphoria by a psychiatrist and requested masculinizing hormone therapy. At the start of therapy, laboratory results, including complete blood count, electrolytes, and lipid panel, were normal.
Which of the following is the most appropriate test to monitor for therapy-related complications?
Hematocrit
Prolactin
Prostate-specific antigen
Serum electrolytes
400
A 32-year-old woman is evaluated in the first trimester of pregnancy for a 2-week history of heat intolerance, palpitations, and tremulousness. Her only medication is folic acid.
On physical examination, pulse rate is 110/min; remaining vital signs are normal. The thyroid is nontender and symmetrically and diffusely enlarged. A fine tremor on the patient's outstretched hands is noted.
Laboratory studies show a thyroid-stimulating hormone level of less than 0.01 μU/mL (0.01 mU/L) and free thyroxine level of 5.3 ng/dL (68 pmol/L).
Which of the following is the most appropriate diagnostic test?
Thyroid scintigraphy with radioactive iodine uptake
Thyroid-stimulating immunoglobulin measurement
Thyroid ultrasonography
Total triiodothyronine measurement
400
A 48-year-old woman is evaluated for a 6-month history of a 9.1-kg (20.1-lb) weight gain and easy bruising. She has newly diagnosed type 2 diabetes mellitus treated with metformin.
On physical examination, vital signs are normal. BMI is 38. The patient has central obesity, supraclavicular and dorsocervical fat pads, and wide violaceous striae on her abdomen.
Laboratory studies show elevated 24-hour urine free cortisol and late-night salivary cortisol levels.
Which of the following is the most appropriate diagnostic test to perform next?
Abdominal CT
Adrenocorticotropic hormone level measurement
8-mg Dexamethasone suppression test
Inferior petrosal sinus sampling