Diabeetus
Which one of the following classes of diabetes medications is most associated with hypoglycemia?
A) Biguanides
B) DPP-4 inhibitors
C) SGLT2 inhibitors
D) Sulfonylureas
E) Thiazolidinediones
D) Sulfonylureas
Sulfonylureas, such as glipizide, glyburide, and glimepiride, commonly cause hypoglycemia as an adverse effect and require glucose monitoring when used. Biguanides most commonly cause diarrhea, vomiting, and other gastrointestinal symptoms. In high-risk patients such as those with heart failure, sepsis, or impaired kidney function, biguanides can also result in lactic acidosis. adverse effects of DPP-4 inhibitors are headache, nasopharyngitis, infections of the urinary tract or upper respiratory tract, and elevated liver enzymes. SGLT2 inhibitors adverse effects such as urinary tract infections, candidiasis, dehydration, and hypovolemia. TZD adverse effects include weight gain, salt retention, edema, and, for some patients, cardiovascular complications.
Which one of the following laboratory tests is best for assessing thyroid function?
A. Free T3
B. Reverse T3
C. Free T4
D. TSH
E. Thyroid peroxidase antibody
D. TSH
The best laboratory assessment of thyroid function is a serum TSH test, which is the preferred test for diagnosing primary hypothyroidism. If an elevated serum TSH level is detected and hypothyroidism is suspected, then a free T4 measurement would be indicated.
A 61-year-old male is found to have a 2-cm right adrenal incidentaloma on CT. He has no history of HTN, electrolyte abnormalities, headaches, flushing, or sweating. Which one of the following studies should be performed in patients found to have an adrenal incidentaloma?
A. ACTH stimulation test
B. Dexamethasone suppression test
C. Paired serum aldosterone & plasma renin activity
D. Serum or urine metanephrines
E. PET scan
B. Dexamethasone suppression test
Which one of the following diabetes mellitus medications is MOST likely to cause weight gain?
A) Empagliflozin (Jardiance)
B) Glimepiride (Amaryl)
C) Liraglutide (Victoza)
D) Metformin (Glucophage)
E) Sitagliptin (Januvia)
B) Glimepiride (Amaryl)
Since many patients with diabetes mellitus are obese, the impact of medications on the patient’s weight is important to consider. Treatment with sulfonylureas, including glimepiride, is associated with weight gain. Empagliflozin, liraglutide, metformin, and sitagliptin are not associated with weight gain. In particular, the SGLT2 inhibitors such as empagliflozin and the GLP1 agonists such as liraglutide are associated with clinically significant weight loss.
14M is brought to your office with a 2-month history of a lump in his left chest. An exam reveals a slightly tender 2-cm area of concentric firm mobile tissue under the left areola. He has no skin changes, nipple discharge, or associated adenopathy. The right side is unremarkable. A genital examination reveals Tanner 3 development but is otherwise unremarkable. Growth curves are appropriate for the patient’s age, with a BMI of 19.1 kg/m2.
Which one of the following would be most appropriate at this point?
A) Follow-up in 6–12 months
B) A prolactin level
C) Ultrasonography of the left breast
D) Tamoxifen (Soltamox), 10 mg/day for 3 months
E) A biopsy
A) Follow-up in 6–12 months
H&P consistent with adolescent physiologic gynecomastia. 1/2 of all adolescent males will have some form of gynecomastia. Often B/L but more common on left if it is U/L. Will typically resolve 6-24 months after onset. Patients should be asked about meds and supplements. Concerning factors include persistence for longer than 2 years; hard, immobile, nontender masses; masses >5 cm; nipple discharge; testicular masses; and systemic symptoms such as weight loss.
26 y/o M was diagnosed with maturity-onset diabetes of the young at age 22. He has a BMI of 24 kg/m2 and his hemoglobin A1c is now 8.5%.
Which one of the following would be most appropriate for this patient?
A. Ketogenic diet
B. Glipizide
C. Metformin
D. Short-acting sliding scale insulin w/ meals
E. Basal insulin at bedtime
B. Glipizide
MODY is a form of DM in nonobese young adults (<30y/o) who have preserved pancreatic -cell function. ~80% of patients w/ MODY are misdiagnosed as having type 1 or type 2 diabetes. These patients exhibit no signs of insulin resistance (metabolic syndrome, acanthosis nigricans, skin tags, androgenic alopecia), are not obese, have positive C-peptide levels, and have a strong family history of DM. MODY does not respond to metformin, but because -cell function is preserved, the hyperglycemia does respond to sulfonylureas. While exercise and a balanced diet of appropriate portions and low carbs are also necessary in patients with MODY, a ketogenic diet is not specifically indicated. Insulin is required only during pregnancy.
A 72-year-old female presents with bothersome palpitations. She is otherwise healthy and is not taking any meds. Exam is normal, including thyroid and eye exams. Labs show serum TSH level of 0.2 U/mL (N 0.4–4.0) and normal T3 and free T4 levels. EKG reveals frequent PACs but is otherwise normal. US of the thyroid does not reveal any nodules, thyroid scintigraphy shows diffuse uptake, and an anti–thyrotropin-receptor (thyroid-stimulating immunoglobulin) antibody level is significantly elevated.
Which is the most likely dx?
A. Central hypothyroidism
B. Graves disease
C. Iodine toxicity
D. Solitary toxic thyroid nodule
E. Toxic multinodular goiter
B. Graves disease
This patient has subclinical hyperthyroidism caused by Graves disease. A positive anti–thyrotropin-receptor (thyroid-stimulating immunoglobulin) antibody result is virtually diagnostic of Graves disease. Central hypothyroidism is associated with a low TSH level and low T3 and T4 levels. Iodine deficiency is associated with goiter and hypothyroidism. Nodular thyroid disease is unlikely given the imaging results. Treatment of this patient’s mild Graves disease is probably indicated, given her age and cardiac symptoms.
36 y/o M sees you for follow-up of progressive fatigue and lightheadedness that has worsened over the past 3 months. He has lost 5 kg (11 lb) during this time. On exam he has a BMI of 21 kg/m2, a BP of 88/48 mm Hg, and HR of 66 beats/min. A skin exam is notable for patches of nonpigmented skin on the hands. Initial labs significant for a sodium level of 132 mEq/L (N 135–145) and a potassium level of 5.3 mEq/L (N 3.5–5.0).
Which one of the following tests would confirm the most likely diagnosis?
A. 17-hydroxyprogesterone
B. ACTH stimulation
C. Dexamethasone suppressin
D. Late night salivary cortisol
E. Plasma renin and aldosterone
B. ACTH stimulation
Consistent with Addison's disease (adrenal insufficiency)
Which one of the following medications for the treatment of type 2 diabetes has been associated with ketoacidosis?
A) Dapagliflozin (Farxiga)
B) Liraglutide (Victoza)
C) Metformin
D) Pioglitazone (Actos)
E) Sitagliptin (Januvia)
A) Dapagliflozin (Farxiga)
SGLT2 inhibitors such as dapagliflozin have increasingly been shown to be associated with diabetic ketoacidosis under certain circumstances. Liraglutide, metformin, pioglitazone, and sitagliptin are not associated with diabetic ketoacidosis.
38F presents for evaluation of infertility after being unable to conceive for the past 14 months. She has a hx of T2DM, obesity, and hypothyroidism, and takes metformin and levothyroxine daily. ROS is notable for menses that occur once every 35–50 days and persistent dark hair growth on her chin and areolae. Exam is remarkable only for BP of 142/95 mm Hg, a BMI of 37 kg/m2, and the hair growth described by the patient.
Which one of the findings in this patient is a required diagnostic criterion for polycystic ovary syndrome?
A) Hyperandrogenism
B) Hypertension
C) Hypothyroidism
D) Infertility
E) Obesity
A) Hyperandrogenism
Several professional organizations have published criteria for the diagnosis of PCOS using various combinations of hyperandrogenism (clinical or biochemical), ovulatory dysfunction (typically oligomenorrhea), and the presence of at least one polycystic ovary by imaging criteria. HTN, hypothyroidism, infertility, and obesity are common symptoms in patients with PCOS but are not diagnostic.
13 y/o M is admitted to the hospital w/ DKA. Aggressive fluid resuscitation with normal saline was initiated in the ED and the following labs were obtained:
Glucose................... 400mg/dL
Sodium ........ 136 mEq/L (N 136–145)
Potassium .......... 2.8 mEq/L (N 3.5–5.1)
Bicarbonate.............. 15mEq/L(N22–29)
Aniongap......... 14mEq/L(N10–20)
In addition to continued fluid resuscitation, which would be the most appropriate next step in the management of this patient?
A) Administration of sodium bicarbonate
B) Potassium replacement
C) An intravenous insulin drip
D) Subcutaneous insulin using a basal/bolus technique
E) Bedside ketone capillary measurement
B) Potassium replacement
A low serum potassium level in diabetic ketoacidosis (DKA) indicates a significant potassium deficiency, placing the patient at risk for a cardiac arrhythmia, among other complications. Potassium deficiency is usually the product of urinary losses due to glucose osmotic diuresis and secondary hyperaldosteronism. However, serum potassium can remain normal when there is a whole body deficiency, as a result of movement of potassium out of cells in response to the acidosis, insulin deficiency, and hyperosmolality. This patient’s serum potassium is low, which indicates severe deficiency.
A 21-year-old gravida 1 para 0 is diagnosed with overt hyperthyroidism early in the first trimester. The most appropriate management at this time is...
A. Observation only
B. Methimazole (Tapazole)
C. Propylthiouracil
D. Radioactive iodine
E. Thyroidectomy
C. Propylthiouracil
Overt hyperthyroidism during pregnancy is associated with adverse effects to the mother and fetus, so treatment is required. Since methimazole is associated with birth defects when used in the first trimester, propylthiouracil is preferred. Methimazole should be considered after the first trimester because the risk of congenital anomalies is less than the risk of liver failure associated with propylthiouracil. Surgery and radioactive iodine should only be used if there is a clear indication, and radioactive iodine would not be appropriate during pregnancy.
28 y/o F presents w/ 3-months of fatigue and postural lightheadedness. On exam she is diffusely hyperpigmented, especially her skin creases and areolae. A CBC and BMP are normal except for an elevated potassium level. You order a corticotropin stimulation test.
Prior to the corticotropin injection, you should order which one of the following tests to confirm that this patient has a primary insufficiency and not a secondary (pituitary) disorder?
A. ACTH
B. Aldosterone
C. Melanocyte-stimulating hormone
D. Renin
E. TSH
A. ACTH
A plasma ACTH level is recommended to establish primary adrenal insufficiency. A plasma ACTH greater than twice the upper limit of the reference range is consistent with primary adrenal insufficiency. Aldosterone and renin levels should be obtained to establish the presence of adrenocortical insufficiency, but these do not differentiate primary from secondary adrenal insufficiency.
55 y/o F w/ T2DM, obesity, and HTN presents for routine follow-up. Despite her best efforts w/ diet & exercise, she has been unable to achieve a healthy BMI. Her current meds include metformin, lisinopril and atorvastatin. Exam shows a BMI of 32 kg/m2 . A1c is 7.5%, which is unchanged from 3 months ago. BMP shows normal electrolytes and renal function.
Which one of the following additional meds would be most likely to improve her glucose control and help her achieve weight loss?
A) Glipizide (Glucotrol)
B) Insulin glargine (Lantus)
C) Liraglutide (Victoza)
D) Nateglinide (Starlix)
E) Sitagliptin (Januvia)
C) Liraglutide (Victoza)
While each of the listed medications has evidence of benefit for improving glycemic control, only the GLP-1 agonist liraglutide would be expected to cause weight loss. SGLT2 inhibitors are also associated with weight loss. Sulfonylureas such as glipizide, insulins such as glargine, and meglitinides such as nateglinide all increase the risk of weight gain. DPP-4 inhibitors such as sitagliptin are weight neutral.
In a patient presenting with truncal obesity, HTN, T2DM, hirsutism, osteopenia, and skin fragility, which one of the following tests is needed to confirm the diagnosis of Cushing syndrome?
A) A dexamethasone suppression test
B) Inferior petrosal sinus sampling
C) Plasma corticotropin
D) Plasma free cortisol
E) Urinary free cortisol
E) Urinary free cortisol
An elevated 24-hr collection showing high urinary free cortisol confirms the presence of Cushing syndrome. The dexamethasone suppression test, though still commonly used, no longer has a place in the dx/tx of patients with Cushing syndrome. Corticotropin-dependent and corticotropin-independent causes of Cushing syndrome can be separated by measuring plasma corticotropin. Plasma free cortisol measurements should be obtained only to determine the success or failure of transsphenoidal microadenomectomy or adrenalectomy. Inferior petrosal sinus sampling is used to confirm the source of corticotropin secretion before surgical intervention.
67 y/o M w/ diabetes mellitus, HTN, and HFrEF has developed stage 5 chronic kidney disease. Which one of the following would be the best option for treatment of his diabetes?
A) Glimepiride (Amaryl)
B) Insulin glargine (Lantus)
C) Metformin
D) Pioglitazone (Actos)
B) Insulin glargine (Lantus)
Patients w/ ESRD and DM need careful monitoring of glucose because insulin requirements are difficult to predict and there is an increased risk of hypoglycemia in this setting. The optimal A1c has not been established but maintaining a value between 6% and 9% does decrease mortality. With close monitoring, insulin is preferred for most individuals. Sulfonylureas such as glimepiride and glyburide are associated with a high risk of hypoglycemia and should be avoided in these patients. Metformin should be avoided in those w/ GFR <30. Pioglitazone should also be avoided in CKD due to the risk of fluid retention and precipitating heart failure.
A 69-year-old male presents for follow-up of HTN treated w/ spironolactone and amlodipine. His PMH is remarkable only for a kidney stone several years ago. Exam is unremarkable. CMP is unremarkable except for a calcium level of 12.0 mg/dL (N 8.0–10.0).
Which one of the following is the most likely cause of his elevated calcium level?
A. Excessive ingestion of calcium supplements
B. His current medication regimen
C. Occult malignancy
D. Primary hyperparathyroidism
E. Vitamin D deficiency
D. Primary hyperparathyroidism
The most common cause of hypercalcemia is hyperparathyroidism. This is seldom symptomatic and is often discovered through routine blood testing. Hypercalcemia due to cancer can be caused by secretion of the parathyroid hormone–related protein and by osteoclastic bone resorption. Other causes of hypercalcemia include thiazide diuretics, lithium, vitamin D intoxication, hyperthyroidism, milk alkali syndrome from excessive calcium antacid ingestion, adrenal insufficiency, and lymphoma.
36 y/o F presents for evaluation of elevated BP. She is asymptomatic and does not take any meds. On exam, BP is 160/96 mm Hg and BMI is 26 kg/m2 . Fasting labs include the following:
Sodium 142 (N 136-145)
Potassium 3.0 (N 3.5-5.1)
Creatinine 0.76 (N 0.6-1.1)
Glucose 97
Which additional lab should be performed to assess her BP?
A. 24-hour urine 5-HIAA
B. Serum aldosterone/renin ratio
C. Serum cortisol level
D. Serum cystatin C level
B. Serum aldosterone/renin ratio
Primary hyperaldosteronism should be suspected as a cause for hypertension if a patient has a spontaneously low potassium level or persistent hypertension despite the use of three or more antihypertensive medications, including a diuretic. This can be evaluated by checking a serum renin activity level and a serum aldosterone concentration and determining the aldosterone/renin ratio. Primary hyperaldosteronism typically presents with a very low serum renin activity level and an elevated serum aldosterone concentration.
38F presents for ongoing management of T2DM, obesity, and chronic abdominal pain related to her history of recurrent pancreatitis. She says that her self-monitored blood glucose has been running in the range of 200–300 mg/dL on most occasions. She is not currently taking any meds but has tried metformin and extended-release metformin unsuccessfully in the past. On both occasions she experienced worsening abdominal pain and diarrhea. She does not feel she can manage insulin and requests an oral medication. Her A1c in your office today is 9.0%.
In addition to lifestyle and nutrition counseling, which one of the following would be the best treatment at this time?
A) Restart metformin
B) Start empagliflozin (Jardiance)
C) Start liraglutide (Victoza)
D) Start sitagliptin (Januvia)
B) Start empagliflozin (Jardiance)
Metformin should be used as 1st-line therapy in T2DM to reduce microvascular complications, assist in weight management, reduce the risk of cardiovascular events, and reduce the risk of mortality in patients. Patients who are intolerant of metformin are unlikely to be successful with a third trial of that agent. Empagliflozin, an SGLT2 inhibitor, is considered a 2nd-line choice for patients who are intolerant of metformin. Both sitagliptin, a DPP-4 inhibitor, and liraglutide, a GLP-1 receptor agonist, should be avoided or used with caution in patients with a history of pancreatitis.
32F presents with heat intolerance, excessive weight loss, and anxiety. She gave birth 6 months ago and recently stopped breastfeeding. On exam her thyroid gland is slightly diffusely enlarged and nontender. Labs reveal a decreased TSH level and elevated free T3 and T4 levels. You suspect that she has postpartum thyroiditis.
Which one of the following tests would be most useful to confirm the diagnosis?
A) Radioactive iodine uptake
B) Thyroid peroxidase antibody levels
C) Thyroid ultrasonography
D) Thyrotropin receptor antibody levels
A) Radioactive iodine uptake
Postpartum thyroiditis= transient or persistent thyroid dysfunction w/in 1 year of childbirth, miscarriage, or abortion. Release of preformed thyroid hormone in the bloodstream initially results in hyperthyroidism. During the hyperthyroid phase, radioactive iodine uptake will be low, which can help to confirm the diagnosis.
12-year-old male w/ T1DM is brought to your office for routine follow-up. Labs performed prior to the appointment shows an LDL of 120 mg/dL.
In addition to counseling the patient on a heart-healthy diet and daily physical activity, which one of the following would you recommend?
A) No additional measures
B) Fish oil supplements
C) Atorvastatin (Lipitor)
D) Ezetimibe (Zetia)
E) Gemfibrozil (Lopid)
C) Atorvastatin (Lipitor)
Pediatric T1DM is recognized as a high-risk condition for the future development of CVD. Current guidelines recommend initiating a statin, in addition to education regarding a healthy diet and physical activity, for pediatric patients in this high-risk category with LDL >100 mg/dL. Statins such as atorvastatin are recommended for 1st-line treatment according to multiple studies that demonstrate their efficacy and benefits in reduction of cardiovascular morbidity and mortality, along with long-term studies demonstrating their safety. Fish oil supplements, ezetimibe, and gemfibrozil would not be appropriate recommendations for this patient at this time.
62-year-old female who is a new patient requests a thyroid eval because she has a history of abnormal thyroid tests. You obtain her records, which include a TSH of 0.2 U/mL (N 0.4–4.2) and a free T4 of 2.0 ng/dL (N 0.8–2.7) from 3 years ago. She is feeling well and has no other health conditions. She does not take any meds.
Exam reveals normal vital signs, a BMI of 23.0 kg/m2, no neck masses, a normal thyroid size, and normal heart sounds. Labs show TSH level of 0.1 U/mL, a free T4 level of 2.5 ng/dL, and a free T3 level of 3.1 pg/mL (N 2.3–4.2).
Treatment for this condition would be indicated if the patient has an abnormal...
A. Calcium level
B. DEXA scan
C. Glucose level
D. Lipid level
E. Thyroid US study
B. DEXA scan
Pt has subclinical hyperthyroidism (low TSH, normal free T4 and T3). May progress to overt hyperthyroidism, but more likely in pts with TSH <0.1. Even in the absence of overt hyperthyroidism these patients are at higher risk for several health conditions, including Afib, CHF, and osteoporosis. Thyroid US may be helpful to determine the cause of hyperthyroidism but is not used to help decide when to treat subclinical hyperthyroidism
39 y/o F presents to your office w/ progressive swelling in the right leg that has spread over the past 2 days. She feels well otherwise. PMH of adrenal insufficiency treated w/ PO prednisone, 5 mg QD, and fludrocortisone, 0.1 mg QD. Exam reveals a temp of 37.8°C (100.0°F), a HR of 88 beats/min, BP of 105/62 mm Hg, and redness, warmth, and swelling in the right lower extremity. You diagnose cellulitis and prescribe appropriate antibiotics.
Which one of the following would be the most appropriate management of her corticosteroid regimen?
A. Continue prednisone & fludrocortisone at the current doses
B. Increase prednisone to 15mg QD & continue fludrocortisone at current dose
C. Increase prednisone to 15mg QD & increase fludrocortisone to 0.3mg QD
D. Stop prednisone until the infection resolves but continue fludrocortisone at current dose
E. Stop both prednisone and fludrocortisone until the infection resolves
B. Increase prednisone to 15mg QD & continue fludrocortisone at current dose.
Patients with chronic adrenal insufficiency, either primary or secondary, may not be able to mount a stress response to infection or surgical procedures. Common practice during minor infections is to increase the corticosteroid supplementation (SOR C). Fludrocortisone should be continued, but stress dosing is not necessary.
72M w/ T2DM sees you for routine follow-up. He takes metformin 1000 mg twice daily. He is sedentary and does not adhere to his diet. His BMI is 32.0. The exam is otherwise wnl. His A1c is 9.5%.
Which one of the following is recommended by the ADA to better control his blood glucose?
A) Start an intensive diet and exercise program for weight loss
B) Start home monitoring of blood glucose with close follow-up
C) Start basal insulin at 10 units/day
D) Stop metformin and start a sulfonylurea
E) Stop metformin and start a basal and bolus insulin regimen
C) Start basal insulin at 10 units/day
According to the ADA's 2018 guidelines for the management of DM, a healthy person with a reasonable life expectancy should have an A1c goal of <7%. Metformin is recommended as 1st-line therapy as long as there are no contraindications. If the A1c is not at the goal or is >9%, then adding another agent to metformin is recommended. Basal insulin at 10 units/day is an acceptable choice for additional therapy to improve blood glucose control. Diet, exercise, and home monitoring of blood glucose are recommended in addition to starting another agent for blood glucose control.
A nulliparous 34-year-old F presents for fatigue, hair loss, and anterior neck pain. Sx have been gradually worsening for the past few months. PMH is unremarkable. She has gained 5 kg (11 lb) since her last visit 18 months ago. Exam of the thyroid gland reveals tenderness but no discrete nodules. Her TSH level is 7.5 U/mL (N 0.4–4.2), her T4 level is low, and her thyroid peroxidase antibodies are elevated.
Which one of the following would be the most appropriate next step?
A) Continue monitoring TSH every 6 months
B) Begin thyroid hormone replacement and repeat the TSH level in 6–8 weeks
C) Begin thyroid hormone replacement and repeat the TSH level along with a T3 level in 6–8 weeks
D) Order ultrasonography of the thyroid
E) Order fine-needle aspiration of the thyroid
B) Begin thyroid hormone replacement and repeat the TSH level in 6–8 weeks
This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8 weeks later. It is not necessary to include a T3 level when assessing the levothyroxine dose. There is no need to routinely order thyroid US when there are no palpable nodules on a thyroid exam. FNA may be necessary to rule out infectious thyroiditis when a patient presents with severe thyroid pain and systemic symptoms.