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Hormones/Endo
Little of Everything
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You make my skin crawl!
PEE-PEE
100
What is the recommended approach for glycemic control in a 42-year-old previously healthy man who is admitted to the intensive care unit and intubated for severe CAP and whose random blood glucose levels are 188, 193, 212 during the first few hours after admission? A. SSI whenever glucose level exceeds 180 B. Continued monitoring, with treatment initiated only if the glucose level exceeds 220 C. Subcutaneous basal glargine insulin injection with daily adjustment until the morning glucose level is < 110 D. IV insulin infusion with target glucose level of 140-180 E. IV insulin infusion with target glucose level of 110-140
What is D. in critically ill patients, Insulin therapy should be initiated to treat persistent hyperglycemia, starting at 140. once therapy is initiated, the American diabetes association recommends a target glucose range of 140-189 SSI is reactive rather than preventive
100
82-year-old women hospitalized for E-coli pyelonephritis and was improving with the use of ampicillin when she experienced a sudden onset of left-sided face, arm, and leg weakness. She reports no chest pain or shortness of breath. Her blood pressure is 240/125. Physical examination reveals findings consistent with an acute left hemiplegia and atrial fibrillation but otherwise unremarkable. There are no carotid bruits. The patient is receiving warfarin for Afib; her most recent INR was 2.6. BMP, UA, CBC unremarkable. CT of the head shows mild brain atrophy consistent with the patient's age and no acute hemorrhage. During this acute phase in the hospital, antihypertensive medications should be initiated if the patient's BP exceeds which of the following A. 185/110 B. 130/85 C. 150/90 D. 220/120 E. 140/90
What is D
100
A 28-year-old pregnant woman is evaluated for a cardiac murmur identified on examination by her obstetrician. She is asymptomatic. She is in her 24th week of pregnancy. Medical history is unremarkable, and there is no family history of heart disease. She takes prenatal vitamins and no other medications. On physical examination, she is afebrile, blood pressure is 120/70 mm Hg, pulse rate is 86/min, and respiration rate is 18/min. Cardiac examination reveals a midsystolic ejection click followed by a grade 3/6 early peaking, crescendo-decrescendo murmur at the right upper sternal border. The murmur radiates toward the apex and decreases slightly with the Valsalva maneuver. No diastolic murmur is heard. What is the most likely cause for the heart murmur?
What is a Bicuspid aortic valve? While the murmur associated with aortic stenosis usually radiates to the carotid arteries, the murmur of a nonstenotic bicuspid aortic valve may radiate to the apex.
100
A 20-year-old male farmer is evaluated for a several-month history of increasing odor and wetness involving both of his feet during the summer months. He otherwise feels well and has no pain or other foot-related symptoms. Medical history is unremarkable, and he takes no medications. Oh physical examination, vital signs are normal. Examination of the feet is notable for a significant malodor. Skin findings are shown. Which of the following is the most appropriate topical treatment? A Clotrimazole cream B Clotrimazole-betamethasone cream C Erythromycin lotion D Hydrocortisone cream
What is C This patient has pitted keratolysis and should be treated with erythromycin lotion. Pitted keratolysis presents with small indented pits on a background of hyperkeratosis and results from increased sweating or perspiration (hyperhidrosis) of the feet. It is a superficial bacterial infection secondary to Kytococcus sedentarius, Corynebacterium, or Actinomyces spp.
100
A hydrocele is found at a 2 month-old visit. When should the child undergo repair if it persists?
What is 1 year of Age. Hydroceles that last past 1 year of age should be surgically repaired. A noncommunicating hydrocele usually resolves before the 1st birthday.
200
which one of the following evaluations is most likely to yield a diagnosis in a patient with weight gain of 15 kg in the past year and daily episode of sweating, palpitations, tremulousness, hunger, and combativeness? A. Measurement of TSH B. Measurement of plasma metanephrine levels C. Collection of 24-hour urine to measure free cortisol D. Measurement of the patient's blood glucose level while symptomatic E. Measurement of Chromogranin A level
What is D***. The combination of hypoglycemia and weight gain is most typical of the diagnosis of insulinoma
200
A 91-year-old woman with advanced dementia is examined in her extended-care facility for a routine evaluation. She is nonverbal, incontinent of urine and stool, largely bedbound, and dependent on others for all activities of daily living. The patient's nurse notes that the patient has continued to lose weight despite being actively fed but raises no other concerns. Medical history is significant for hypertension, and her only medication is amlodipine. On physical examination, blood pressure is 132/87 mm Hg; other vital signs are normal. The patient appears cachectic with temporal wasting. She is awake but is unresponsive to questions. Mucous membranes are moist. She does not appear to have any pain. There are mild early contractures of her ankles and hips. The remainder of the examination, including skin examination, is unremarkable. Which of the following is the most appropriate intervention for preventing pressure ulcers in this patient? A Alternating-air mattress B Enteral nutrition C Foam mattress overlay D Frequent repositioning
What is C A clinical practice guideline issued by the American College of Physicians (ACP) recommends the use of advanced static mattresses (a mattress made of foam or gel that does not move when a person lies on it) or an advanced static overlay (a material such as sheepskin or a pad filled with air, water, gel, or foam that is secured to the top of a bed mattress) to prevent pressure ulcers in at-risk individuals. These interventions have been found to lower the risk of pressure ulcers relative to standard hospital mattresses. Advanced static mattresses and overlays work by redistributing pressure and reducing shear that may lead to development of ulcers. Frequent repositioning is often performed as a component of multimodal interventions to prevent pressure ulcers. Such multimodal interventions have been shown to be beneficial; however, there is a paucity of studies of repositioning alone and no good evidence to support repositioning alone as a pressure ulcer prevention tool. Nonetheless, repositioning should always be a part of a multimodal approach to pressure ulcer prevention.
200
A 53-year-old woman with Eisenmenger syndrome related to a ventricular septal defect is evaluated in the emergency department for fever and chills over the past 12 hours. She has dysuria and urinary frequency. Her only outpatient medication is bosentan. On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 110/70 mm Hg, pulse rate is 86/min and regular, and respiration rate is 20/min. Oxygen saturation on ambient air is 85%. BMI is 24. Digital clubbing and cyanosis are evident. The estimated central venous pressure is elevated with a prominent a wave. The apical impulse is normal. A prominent parasternal impulse is present at the left sternal border. The S1 is normal; the S2 is loud. A soft holosystolic murmur is heard at the left lower sternal border. Mild right flank tenderness is noted. A urinary Gram stain is positive; urine and blood culture results are pending. The hemoglobin level is 18 g/dL (180 g/L), hematocrit is 55%, and the leukocyte count is 20,000/µL (20 × 109/L). In addition to intravenous antibiotic administration, which of the following is the most appropriate management? 15% A Air filters on intravenous lines B Oxygen by close-fitting mask C Phlebotomy D Transthoracic echocardiogram ****DOUBLE IF STATED WHY!****
What is A. In this patient with Eisenmenger syndrome, air filters on intravenous lines are recommended to reduce the risk of paradoxical air embolism which is caused by intracardiac right-to-left shunt
200
A 32-year-old woman is evaluated for a rash on her face and arms of 2 months' duration. The rash developed progressively and has not responded to topical moisturizers and an over-the-counter glucocorticoid. The patient also has a moderate nonproductive cough, but otherwise feels well. Medical history is significant only for a 15-pack-year smoking history, although she quit smoking 4 months ago. She takes no medications. On physical examination, vital signs are normal. BMI is 32. The lungs are clear. Skin findings are shown. Her hair is normal, and she has no scarring or lesions in the ears or on the cheeks. A chest radiograph is shown. Which of the following is the most likely diagnosis?
What is Sarcoidosis Sarcoidosis is a granulomatous, infiltrating disease that is more common in black persons and may be incidentally discovered by detection of lymphadenopathy, often in the chest. A chronic, nonproductive cough is the most common pulmonary symptom of sarcoidosis, as occurs in this patient. The cutaneous manifestations of sarcoidosis result from granulomatous infiltration in the skin with papule formation at the site of disease. Lesions tend to be grouped around the nose and are sometimes seen around the eyes or mouth. Sarcoidal involvement of tattoos and scars is not uncommon. Smoking may alter the pulmonary immune milieu, and smokers tend to have a lower incidence of sarcoidosis, with some patients occasionally developing sarcoidosis after smoking cessation. However, smoking is not recommended as a preventive or therapeutic measure. Medium-potency topical glucocorticoids are the usual first-line therapy for cutaneous sarcoidosis on the face, with high-potency agents used in other lower risk sites. Intralesional glucocorticoids are also a treatment option.
200
An 8-Year-old boy presents with Current severe sore throat, Cola-colored urine, HTN what is the most likely diagnosis?
What is IgA Nephropathy (Berger Nephropathy) The key here is that a sore throat is occurring at the same time as the hematuria; thus, this is most likely IgA nephropathy- Remember that with acute postinfectious glomerulonephritis you have a latent period of 1-2 weeks.
300
Which of the following treatments is the most appropriate in the care of a 72-year-old woman who reports a persistent ache in her right leg and is found to have an elevated alkaline phosphatase level and cortical thickening of the tibia without an underlying mass? A. Treatment with calcitriol B. Biopsy of the area of cortical thickening C. Treatment with alendronate D. Treatment with teriparatide E. Treatment with cinacalcet
What is C. The best treatment for active paget disease is a bisphosphonate. This is a monostotic paget disease.
300
A 45-year-old man is evaluated during a routine examination. He is interested in quitting smoking. He has a history of seizures but has not had a seizure in 15 years and discontinued his seizure medication 4 years ago. He also has hypertension. His only medication is amlodipine. Physical examination is unremarkable. Which of the following will most likely give this patient the greatest chance of success in quitting smoking? A. Bupropion B. Electronic cigarettes C. Nicotine replacement patches D. Varenicline
What is D. Varenicline will most likely give this patient the greatest chance of success in quitting smoking. A recent Cochrane meta-analysis showed that varenicline increased the odds of quitting smoking compared with placebo (OR, 2.88; 95% CI, 2.40-3.47). Although concerns have been raised regarding varenicline use and an increase in cardiovascular events, the FDA noted that the benefits outweigh potential risks in terms of cardiovascular risk. Varenicline was also found to be more effective than the nicotine patch and nicotine gum, and the nicotine inhaler, spray, tablets, or lozenges all used as single agents.
300
A 56-year-old woman is evaluated during an appointment to establish care. She has a developmental delay, and she is known to have pulmonary hypertension due to a congenital cardiac condition. There is no history of cardiac surgery. She is on low-dose aspirin and thyroid replacement therapy. On physical examination, blood pressure is 110/70 mm Hg, pulse rate is 68/min and regular, and respiration rate is 18/min. BMI is 32. The central venous pressure is elevated with a prominent a wave. The apical impulse is normal. There is a prominent parasternal impulse at the left sternal border. The S1 is normal; the S2 is loud. There is a grade 1/6 holosystolic murmur at the left lower sternal border. The toes demonstrate cyanosis and digital clubbing; her hands appear normal. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of this patient's pulmonary hypertension? A Atrial septal defect B Patent ductus arteriosus C Tetralogy of Fallot D Ventricular septal defect
What is B. The patient has a patent ductus arteriosus (PDA) with secondary pulmonary hypertension (Eisenmenger syndrome). Clinical features of an Eisenmenger PDA include clubbing and oxygen desaturation affecting the lower body. This differential cyanosis and clubbing are caused by desaturated blood reaching the lower part of the body preferentially.
300
A 53-year-old man is evaluated for itching lasting 5 months. He reports that his whole body is itchy and that a short course of emollients and antihistamine medication did not improve his symptoms. He feels well otherwise. Review of systems is negative including findings for fever, fatigue, and unintentional weight loss. He does not take any medications. On physical examination, vital signs are normal. Examination of the skin reveals no signs of xerosis or inflammation. Excoriations are noted on his legs, shoulders, and back. The remainder of the physical examination, including thyroid and lymph node examinations, is normal. A complete blood count, metabolic profile, serum thyroid-stimulating hormone level, liver chemistry tests, and HIV antibody assay are normal. Which of the following is the most appropriate next step in management? A Chest radiograph B CT scan of the chest, abdomen, and pelvis C Skin biopsy D No further testing
What is A. The next step in managing this patient's pruritus is to obtain a chest radiograph for possible Hodgkin lymphoma, which is the malignant disease most strongly associated with pruritus. When primary skin lesions are absent, especially when pruritus is generalized, systemic causes of pruritus are suspected. A CT scan of the chest, abdomen, and pelvis is not recommended without earlier studies that indicate the need for widespread imaging.
300
What are the most common sites for thromboses in a child with nephrotic syndrome? (List 2)
What is Renal Veins and Sagittal sinus? In children with nephrotic syndrome, the renal vein and sagittal sinus are the most common location for clots, followed by the pulmonary and femoral arteries. Almost all nephrotic children have a hypercoaguable state, and about 20% will have a thrombotic event that is clinically silent
400
53-year-old women have been treated with 100 micrograms of levothyroxine daily since being diagnosed with Hashimoto Thyroiditis at 32 years of age. Her TSH levels have ranged from 1.2 to 2.6. She reports some fatigue that she believes is from hot flashes in the setting of menopause. She has a history of HTN, controlled with HCTz. About 6 months ago, she became aware of vitamin recommendations for menopausal women and began taking a combined calcium-Vit D supplementation BID with multivitamin QAM with her HCT and levothyroxine. TSH now is 16.8. PE shows atrophic thyroid but the remainder of PE is unremarkable. What is the most likely cause of this patient's increase in TSH hormone level?
What is Coadministration of levothyroxine and Calcium? Two dietary supplements that can impair levothyroxine absorption are calcium and iron.
400
A 17 yo female returns from Brazil having spent a few weeks there on a medical mission. Within 2 days of returning she experiences high fever and states she wants to jump out of her skin. Associated findings include HA, nausea, vomiting, arthralgia and myalgia as well as rash over her trunk and extremities? What is the most likely diagnosis and what vector caused this problem
What is Dengue Fever and mosquito?
400
A 26-year-old woman with a mechanical mitral valve prosthesis visits to discuss anticoagulation management during pregnancy. Her last menstrual period was 6 weeks ago and her pregnancy was confirmed by laboratory testing in the office. Her mitral valve was replaced 5 years ago. Her medications are low-dose aspirin, metoprolol, and warfarin (4 mg/d). On physical examination, vital signs are normal. Cardiac auscultation demonstrates a normal mechanical S1. There are no murmurs or added sounds. Her INR is 2.6. Which of the following anticoagulation regimens will provide the greatest protection against thromboembolism during her pregnancy? A Continue warfarin and aspirin B Stop warfarin and start dabigatran C Stop warfarin and start subcutaneous fixed-dose unfractionated heparin D Stop warfarin and start weight-based low-molecular-weight heparin
What is A. Women with mechanical valve prostheses carry a high risk of valve thrombosis, bleeding, and fetal morbidity and mortality during pregnancy, and the optimal anticoagulation strategy has not been established. Options include warfarin, unfractionated heparin (UFH), and low-molecular-weight heparin (LMWH). Although warfarin poses an increased risk of teratogenicity and fetal loss, it appears to be the most effective option for reducing thromboembolism risk in the mother.
400
A 38-year-old woman is hospitalized for a rash that developed during antibiotic treatment for pyelonephritis. She was diagnosed 1 week ago and was started on a 10-day course of trimethoprim-sulfamethoxazole based on urine culture results. Although her urinary tract symptoms have resolved, yesterday she noted the onset of a widespread, itchy rash. She also notes some facial swelling but has no difficulty breathing. Medical history is otherwise unremarkable, and she is taking no other medications. On physical examination, temperature is 38.5 °C (101.3 °F). Her mucous membranes are normal. She has 3-cm lymph nodes in the anterior cervical and axillary regions and a liver edge palpable 4 cm below the costal margin. Skin findings are shown. What is the diagnosis and list the first management step? Double: list the 2nd management step
What is DRESS SYNDROME Double: CBC, Liver chemistry test The presence of DRESS should be suspected in patients with a morbilliform rash, fever, facial swelling, and lymphadenopathy that occur 5 to 10 days after starting a potentially offending medication. The initial diagnostic approach in suspected DRESS is to assess for evidence of systemic organ involvement, and this is accomplished by obtaining a complete blood count, which may show atypical lymphocytosis and eosinophilia, and liver chemistry studies, which may show aminotransferase elevations. Patients with extensive cutaneous reactions or evidence of organ involvement may require hospitalization and possibly treatment with systemic glucocorticoids. Even if the rash fades, the patient can still progress to liver failure.
400
A young boy presents with the following: Absence of, or deficiency in abdominal wall musculature; cryptorchidism; dilation of the prostatic urthra, bladder and ureters. What is the syndrome with these findings?
What is Prune Belly Syndrome (Eagle Barrett Syndrome, Urethral Obstruction Malformation Complex) Prune Belly syndrome occurs in boys 95% of the time. It can have a varied presentation, but the most common is a group with significant anatomical genitourinary anomalies, but initially normal renal function. Can be confused with PUV in utero.
500
18-year-old presents for follow up 2 months after undergoing craniotomy for resection of a craniopharyngioma, which was discovered during an evaluation of absent pubertal development and panhypopituitarism. The patient reports feeling well except for intermittent fever as high as 39 C at home and an increased appetite. His current medication are levothyroxine 112 microgram once daily, Hydrocortisone 20 mg Qam and 10 mg Qpm, desmopressin nasal spray, and testosterone IM injections. On examination, the patient's temperature is 38.8, HR 97, BP 129/88, BMI 34.2. His craniotomy scare is well healed with no erythema, tenderness or drainage. There is no nuchal rigidity. The remainder of PE is normal. Laboratory showed Na of 146, TSH of 0.051, Free Thyroxine level is 1.8. During the 2 weeks before this follow up visit, two sets of Bcx, UA, and Ucx, analysis of CSF and CXR were all normal. an MRI of the head revealed expected postoperative changes. What is the most likely cause of patient's fever?
What is Hypothalamic dysfunction. The most typical manifestation of anatomical problem of the hypothalamus are changes in appetite, changes in thirst, and dysregulationof sleep and body temperature.
500
What medication is most appropriate for an overweight 24-year-old woman with Polycystic ovary syndrome who is bothered by hirsutism that persists despite treatment with an oral contraceptive pill?
What is Spironolactone Spironolactone is an androgen and mineralocorticoid-receptor blocker. Effective and safe and is the preferred drug for patients who have an elevated testosterone level and persistent hirsutism despite treatment with an oral contraceptive pill. Metformin has been shown to benefit patients with PCOS who have hyperglycemia and/or infertility. but it is not effective for managing hirsutism.
500
A 74-year-old man is evaluated 4 months after undergoing uncomplicated bioprosthetic surgical aortic valve replacement. Within the past 2 weeks, he has developed exertional dyspnea, fatigue, and lower extremity edema. Medical history is otherwise unremarkable, and he takes no medications. On physical examination, vital signs are normal. The estimated central venous pressure is 12 cm H2O, and the jugular venous pulse shows prominent y descents. A pericardial knock is present. Peripheral edema is noted. An echocardiogram reveals no evidence of pericardial effusion. The aortic and mitral valves are functioning normally. The inferior vena cava is markedly enlarged. A Doppler ultrasound shows expiratory flow reversals in the hepatic veins consistent with constrictive pericarditis. Which of the following is the most appropriate next step in management? A Ibuprofen B Invasive cardiac hemodynamic evaluation C Pericardiectomy D Transesophageal echocardiography
What is A. In some patients with constrictive pericarditis, the constriction can be transient and either spontaneously resolve or respond to medical therapy. Pericardiectomy is inappropriate before a 2- to 3-month trial of anti-inflammatory medication in this patient. Although pericardiectomy is the definitive treatment for relief of heart failure in patients with constrictive pericarditis, it is a complex, invasive procedure that should not be used in patients with transient constriction.
500
A 52-year-old man is evaluated in the hospital for several skin lesions on his back, chest, and arms. The patient has acute myeloid leukemia and was hospitalized after developing neutropenic fever 10 days following his initial course of chemotherapy. The skin lesions first appeared the day his fever started. Medications are vancomycin and cefepime. On physical examination, temperature is 38.4 °C (101.2 °F), blood pressure is 110/70 mm Hg, pulse rate is 95/min, and respiration rate is 18/min. A representative skin lesion is shown. Hemoglobin 8.2, Leukocyte count 400/µL with 95% neutrophils, Platelet count 10,000/µL (10 × 109/L) Metabolic profile -Normal, Urinalysis- Normal, Chest radiograph is normal. Blood cultures show no growth to date. What is the name of the syndrome?
What is Sweet Syndrome This patient has the typical skin findings characteristic of Sweet syndrome, also known as acute febrile neutrophilic dermatosis. The lesions are well demarcated with a sharp cut-off separating normal and inflamed skin. Because of the intense neutrophilic inflammatory infiltrate and accompanying papillary dermal edema, the lesions are often referred to as appearing “juicy.” Patients often have a leukocytosis with a predominance of neutrophils and bands; there may be an accompanying, albeit nonspecific, elevation in inflammatory markers such as erythrocyte sedimentation rate. Patients with Sweet syndrome may have idiopathic disease (common in older white women) or paraneoplastic Sweet syndrome, most commonly seen in patients with hematologic malignancies, particularly acute myeloid leukemia or myelodysplastic syndrome. The sharply demarcated, indurated red papules, plaques, or nodules almost always develop in the setting of fever and are often mistaken for infection. Patients may develop these lesions at any time during their treatment course. Sweet syndrome may also occur as a reaction to certain medications, particularly granulocyte colony-stimulating factors. The condition is extraordinarily responsive to treatment with glucocorticoids, with the fever stopping immediately and the lesions fading within 1 to 2 days.
500
Which specific antibody is commonly found in granulomatosis with polyangiitis (Wegener's)?
What is Anti-proteinase-3 (PR3), which produces a c-Anca pattern, is sensitive and specific for GPA