Question 1

A 48-year-old woman has sustained 2 left metatarsal fractures in the past 18 months and is found to have low bone density (mean total hip T score of –2.4). She has a history of poorly controlled hypertension, and her cardiologist performs a chest CT to exclude coarctation of the aorta (negative), but a 1.4-cm left adrenal nodule (2 Hounsfield units) is discovered. Her medications are lisinopril, amlodipine, and metoprolol.

On physical examination, her blood pressure is 152/96 mm Hg and pulse rate is 64 beats/min. Her height is 64 in (162.6 cm), and weight is 136 lb (61.8 kg) (BMI = 23.3 kg/m2). Examination findings are normal.

Laboratory test results:

  • Electrolytes, normal
  • Serum aldosterone = 9 ng/dL (1-21 ng/dL) (SI: 249.7 pmol/L [27.7-285.5 pmol/L])
  • Plasma renin activity = 7.3 ng/mL per h (0.6-4.3 ng/mL per h)
Which of the following would be the most sensitive test for the diagnosis of autonomous cortisol secretion from this nodule?

A. Early-morning serum cortisol measurement

B. 24-hour urinary free cortisol measurement

C. Late-night salivary cortisol measurement

D. MRI of adrenal glands

E. Overnight 1-mg dexamethasone suppression test

Question 2

A 24-year-old woman is referred for evaluation after developing hyperglycemia during a hospitalization for pneumonia. She has cystic fibrosis and was admitted to the hospital last month for an exacerbation of chronic pulmonary disease thought to be due to bacterial infection. During the early period of her hospital stay for antibiotic treatment, several blood glucose values were documented to be greater than 200 mg/dL (>11.1 mmol/L), but not persisting for more than 48 hours. Fasting blood glucose levels were below 100 mg/dL (<5.6 mmol/L) the 2 days before discharge. She had been generally well in the year before hospitalization, but she did note an 8.8-lb (4-kg) weight loss over that time.

On physical examination, her BMI is 22 kg/m2. She has a resonant chest with decreased breath sounds and decreased muscle mass and subcutaneous fat.

Which of the following is the most appropriate diagnostic strategy now?

A. Oral glucose tolerance test

B. Continuous glucose monitoring

C. Hemoglobin A1c measurement

D. A mixed-meal tolerance test

E. Measurement of fasting blood glucose on 2 occasions

Question 3

A 27-year-old woman with a 3-year history of nephrotic syndrome is found to have the following laboratory values:

  • Serum calcium = 7.8 mg/dL (8.2-10.2 mg/dL) (SI: 2.0 mmol/L [2.1-2.6 mmol/L])
  • Serum creatinine = 1.0 mg/dL (0.6-1.1 mg/dL) (SI: 88.4 µmol/L [53.0-97.2 µmol/L])
  • Phosphorus = 2.6 mg/dL (2.3-4.7 mg/dL) (SI: 0.8 mmol/L [0.7-1.5 mmol/L])

She reports no paresthesias or muscle cramps.

On physical examination, she has 2+ pitting pretibial edema but the Trousseau and Chvostek signs are absent.

Which of the following would be most useful to measure next to determine the etiology of her low serum calcium level?

A. Serum PTH

B. Serum 25-hydroxyvitamin D

C. Serum 1,25-dihydroxyvitamin D

D. Serum magnesium

E. Serum albumin

Question 4

A 49-year-old man with a history of morbid obesity, hypothyroidism, and type 2 diabetes mellitus underwent gastric bypass 14 months ago. His preoperative BMI was 42 kg/m2. After surgery, his diabetes went into remission and his insulin therapy was stopped. His weight decreased and stabilized at a BMI of 29 kg/m2. He was told to take a potent multivitamin; calcium, 1200 mg daily; and sublingual vitamin B12, 500 mcg daily. He has not had any follow-up for the last 4 months. Over the past month, he has had several episodes where he felt shaky, sweaty, and irritable. A family member brought him to the emergency department yesterday at 11:00 AM for confusion that apparently developed after he had a large breakfast at a buffet restaurant. A glucose level of 35 mg/dL (1.9 mmol/L) was documented.

Laboratory test results (fasting):

  • Glucose = 49 mg/dL (70-99 mg/dL) (SI: 2.7 mmol/L [3.9-5.5 mmol/L])
  • Insulin = 1.6 µIU/mL (1.4-14.0 µIU/mL) (SI: 11.1 pmol/L [9.7-97.2 pmol/L])
Which of the following is the most appropriate treatment?

A. Low-carbohydrate diet

B. Hydrocortisone

C. Partial pancreatectomy

D. Octreotide

E. Diazoxide

Question 5

A 48-year-old woman with a 38-year history of type 1 diabetes mellitus has been on insulin pump therapy for 11 years with a rapid-acting insulin analogue. She has recently been experiencing recurrent high fasting blood glucose values and random episodes of hypoglycemia. You examine her log book, which documents self-monitored blood glucose levels 4 to 5 times daily before meals, several glucose values at random times in the 40s and 50s, and fasting levels most mornings in the high 100s to low 200s, although occasional values of 70 to 150 mg/dL are noted. She has a bedtime snack of 15 g of carbohydrate each evening. The patient reports that she has no symptoms associated with the low blood glucose values. She is asking for advice about achieving better glycemic control.

Which of the following is the best recommendation?
 

A. Begin monitoring glucose levels with a continuous glucose sensor

B. Increase the basal insulin rate 2 hours before the time that fasting hyperglycemia is occurring

D. Give a bolus of insulin to cover her bedtime snack

E. Eliminate the bedtime snack

Question 6

A 55-year-old woman with bipolar disorder is prescribed lithium therapy. Before starting therapy, she is noted to have a small, firm goiter. Her family history is notable for a sister with Graves disease.

Laboratory test results:

  • Serum TSH = 2.9 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 1.0 ng/dL (0.8-1.8 ng/dL) (SI: 12.9 pmol/L [10.30-23.17 pmol/L])
In this patient, which of the following is the best predictor of thyroid dysfunction over the next 3 months?

A. Thyroid nodules on ultrasonography

B. Positive family history of thyroid disease

C. Serum thyroglobulin level

D. Positive TPO antibodies

E. Elevated serum lithium levels

Question 7

A 25-year-old woman with polycystic ovary syndrome presents to discuss contraceptive options. Her menarche was at age 11 years, and her menses have always been irregular. She had onset of hirsutism and acne at age 12 years and both have progressed since adolescence. She is currently using barrier contraceptives. Her weight increased during college, and her BMI is now 29 kg/m2. Her blood pressure is 110/70 mm Hg.

Which of the following contraceptive methods would be best for this patient?

A. Levonorgestrel-releasing intrauterine device

B. Oral contraceptive containing drospirenone

C. Spironolactone

D. Medroxyprogesterone

E. Long-acting GnRH analogue

Question 8

A 28-year-old woman with type 1 diabetes mellitus is estimated to be 6 weeks pregnant. Her diabetes is complicated by retinopathy, albuminuria, and hypertension treated with lisinopril. She is using a combination of basal insulin with fixed prandial doses of a rapid-acting insulin analogue. Her overnight (3 AM) and fasting blood glucose levels range between 110 and 122 mg/dL (6.1 and 6.8 mmol/L), and her 1-hour postprandial glucose levels range between 112 and 129 mg/dL (6.2 and 7.2 mmol/L).

In addition to stopping lisinopril, which of the following should you recommend during this pregnancy?
 

A. Increase basal insulin to achieve fasting glucose levels &lt;90 mg/dL (&lt;5.0 mmol/L)

B. Start prandial supplemental insulin to achieve 1-hour postprandial glucose levels &lt;120 mg/dL (&lt;6.7 mmol/L)

C. Begin insulin administration via a continuous subcutaneous insulin infusion pump

D. Continue to monitor hemoglobin A1c every 3 months

E. Recommend no therapy changes; her current level of glycemic control is adequate

Question 9

A 17-year-old boy is referred for evaluation of delayed puberty. He is very embarrassed about his appearance in the locker room. He does not shave and has sparse body hair. His father recalls that he himself experienced a “late puberty.” The patient has a normal sense of smell.

On physical examination, his height is 66 in (167.6 cm) and BMI is 21 kg/m2. He has no facial or pubic hair and minimal axillary hair. He does not have cleft palate. There is no gynecomastia. He has a normal phallus with no hypospadias, and his testes are small (4 mL bilaterally).

Laboratory test results:

  • Total testosterone = 20 ng/dL (300-1000 ng/dL) (SI: 0.7 nmol/L [10.4-34.7 nmol/L])
  • LH = 0.5 mIU/mL (1.8-15 mIU/mL) (SI: 0.5 IU/L [1.8-15 IU/L])
  • FSH = 2.5 mIU/mL (1.8-15 mIU/mL) (SI: 2.5 IU/L [1.8-15 IU/L])
  • Serum IGF-1, normal
  • Free T4, normal
  • TSH, normal
  • Iron studies, normal
  • Cosyntropin stimulation test, normal

Sellar imaging is normal.

Which of the following would you recommend?

A. Observe until age 18 years, then consider testosterone therapy

B. Clomiphene, 50 mg daily

C. Testosterone gel, 5 g daily

D. Testosterone gel, 10 g daily

E. Testosterone enanthate, 50 mg monthly

Question 10

A 27-year-old woman with an 18-year history of type 1 diabetes mellitus presents for follow-up. She has been on insulin pump therapy for 3 years. Her hemoglobin A1c level is currently 6.4% (46 mmol/mol).

She reports frequent hypoglycemia, particularly between meals or before sleep, and she has decreased recognition of hypoglycemia. She is frustrated by weight gain over the last 2 years and has tried to reduce her carbohydrate intake, but finds this effort has resulted in more hypoglycemia.

Insulin pump settings are listed. Basal rates are as follows:

Midnight          0.6 units/h       
3 AM               0.525 units/h    
9 AM               0.55 units/h       
9 PM               0.525 units/h    

  • Insulin-to-carbohydrate ratio: 1:7 g of carbohydrate
  • Sensitivity ratio: 1:50
  • Target glucose: 130 mg/dL (7.2 mmol/L)

Review of her individual glucose levels confirms frequent monitoring with many values less than 60 mg/dL (<3.3 mmol/L) during the day, often about 2 to 3 hours after meals. Download of data from her pump reveals the average total daily dose of insulin to be 33.35 units and the dose of basal insulin to be 13.125 units. She averages about 138 g of carbohydrates daily. She usually changes her sets every 3 days.

Measurement

Prebreakfast

Prelunch

Pre-evening Meal

Bedtime

Glucose, mean (±SD)

145 ± 48 mg/dL
(8.0 ± 2.7 mmol/L)

111 ± 73 mg/dL
(6.2 ± 0.4 mmol/L)

127 ± 89 mg/dL
(7.0 ± 4.9 mmol/L)

138 ± 81 mg/dL
(7.7 ± 4.5 mmol/L)

Which of the following would be the most appropriate change in her treatment regimen?

A. Increase the carbohydrate content in her diet

B. Change the insulin-to-carbohydrate ratio to 1 unit per 12 g of carbohydrate

C. Decrease the daytime basal rate by 15%

D. Decrease basal and bolus insulin doses by 10%

E. Decrease the sensitivity ratio to 1:75

Question 11

A 35-year-old woman is referred to you for evaluation of hyperphosphatemia. As you elicit a medical history, the patient reports that she began to develop calcium deposits in different body sites at age 5 years. Initially, the affected areas were her right elbow and left calf, and the deposits were surgically removed. Since then, she has had nearly a dozen of these nodules on her hands, feet, chest wall, and breasts. They developed less frequently after puberty. When she was a child, blood work revealed an elevated phosphorous level. She was treated with dietary modification and, for a few years, with aluminum-containing antacids. For the past 6 years, she has followed a diet with limited phosphorous intake.

She has 1 child, age 10 years, who has normal phosphorous levels and no calcium deposits. Because the placenta was highly calcified at birth, the patient elected to have no other children. She uses oral contraceptives for birth control.

On physical examination, her blood pressure is 102/62 mm Hg and pulse rate is 62 beats/min. Her height is 63 in (160 cm), and weight is 110 lb (50 kg) (BMI = 19.5 kg/m2). Physical examination findings are normal except for small soft-tissue calcifications in her right hand (see image), right arm near the elbow, left calf, and both breasts.

Results from a chemistry panel:

  • Creatinine = 1.0 mg/dL (0.6-1.1 mg/dL) (SI: 88.4 µmol/L [53.0-97.2 µmol/L])
  • Calcium = 9.5 mg/dL (8.2-10.2 mg/dL) (SI: 2.4 mmol/L [2.1-2.6 mmol/L])
  • Phosphorus = 6.2 mg/dL (2.3-4.7 mg/dL) (SI: 2.0 mmol/L [0.7-1.5 mmol/L])
  • Albumin = 4.4 g/dL (3.5-5.0 g/dL) (SI: 44 g/L [35-50 g/L])
  • 25-Hydroxyvitamin D = 44 ng/mL (25-80 ng/mL [optimal]) (SI: 109.8 nmol/L [62.4-199.7 nmol/L])
  • 1,25-Dihydroxyvitamin D = 38 pg/mL (16-65 pg/mL) (SI: 98.8 pmol/L [41.6-169.0 pmol/L])
  • PTH = 17.3 pg/mL (10-65 pg/mL) (SI: 17.3 ng/L [10-65 ng/L])
  • Urinary calcium = 70 mg/24 h (0.8 g creatinine in sample) (100-300 mg/24 h) (SI: 1.8 mmol/d [2.5-7.5 mmol/d])
An inactivating mutation in the gene encoding which of the following proteins is the most likely cause of hyperphosphatemia in this patient?

A. Calcium-sensing receptor

B. Sclerostin

C. PTH receptor

D. Vitamin D receptor

E. Fibroblast growth factor 23

Question 12

A 45-year-old man is referred to you because of increased transaminase levels while on statin therapy. Six months ago, the patient’s primary care physician prescribed atorvastatin, 40 mg daily (his off-statin LDL-cholesterol concentration was 170 mg/dL [4.40 mmol/L]). He has hypertension controlled on an ACE inhibitor, and he quit smoking cigarettes 2 years ago after a 30 pack-year history. His father died suddenly at age 48 years. The patient’s BMI is 31 kg/m2 and he does not exercise regularly.

Laboratory test results:

  • Hemoglobin A1c = 5.8% (4.0%-5.6%) (40 mmol/mol [20-38 mmol/mol])
  • TSH, normal
  • Total cholesterol = 170 mg/dL (<200 mg/dL [optimal]) (SI: 4.40 mmol/L [<5.18 mmol/L])
  • HDL cholesterol = 55 mg/dL (>60 mg/dL [optimal]) (SI: 1.42 mmol/L [>1.55 mmol/L])
  • Triglycerides = 200 mg/dL (<150 mg/dL [optimal]) (SI: 2.26 mmol/L [<3.88 mmol/L])
  • LDL cholesterol = 75 mg/dL (<100 mg/dL [optimal]) (SI: 1.94 mmol/L [<2.59 mmol/L])
  • ALT = 72 U/L (10-40 U/L) (SI: 1.20 µkat/L [0.17-0.67 µkat/L])
  • AST = 80 U/L (20-48 U/L) (SI: 1.34 µkat/L [0.33-0.80 µkat/L])
Which of the following is the best next step?

A. Stop atorvastatin and change to pravastatin

B. Stop atorvastatin and remeasure transaminase levels off therapy

C. Measure creatine phosphokinase

D. Stop atorvastatin and start a PCSK9 inhibitor

E. Continue atorvastatin

Question 13

A 25-year-old woman is referred to a gynecologist because of oligomenorrhea over the past several years. At first, she began to skip occasional periods, but the interval between menstrual periods has increased in length and she has had only 2 periods over the last year.

Pelvic examination findings are normal, and she does not have acne or hirsutism. Her height is 66 in (167.6 cm), and weight is 171 lb (77.7 kg) (BMI = 27.6 kg/m2). Her serum prolactin concentration is 210 ng/mL (9.1 nmol/L), confirmed on serial dilution. She does not report galactorrhea, but on physical examination, her gynecologist is able to express whitish secretory product from both nipples.

In taking a history, you learn that the patient had to interrupt a year in college because she developed schizophrenia. Initially, she was treated with olanzapine, but she did not want to continue it because she gained weight. After trying several other antipsychotic medications, she was prescribed risperidone, which has been helpful.

Which of the following is the best next step?

A. Change her antipsychotic medication

B. Test for macroprolactinemia

C. Measure IGF-1

D. Add bromocriptine

E. Order pituitary MRI

Question 14

Which of the following nodules is most likely to have an FNAB result suggestive of thyroid cancer?

A. Figure A

B. Figure B

C. Figure C

D. Figure D

Question 15

A 27-year-old woman with a 7-year history of infertility presents for evaluation. The patient has polycystic ovary syndrome with symptoms of irregular menses and hyperandrogenism. She describes irregular menses every 6 to 8 weeks since menarche at age 12 years. She shaves her face twice weekly. She married 7 years ago. She and her husband have never used contraception. Starting 1 year ago, she was treated with 6 cycles of clomiphene citrate, which included ultrasounds documenting follicle growth and ?-hCG injections to ensure ovulation. She did not become pregnant. At the time of her marriage 7 years ago, she weighed 120 lb (54.5 kg), but she has gained more than 70 lb (31.8 kg) in the last 4 years. Her husband, who works out regularly as a body builder, has taken her to the gym and helped her lose 20 lb (9.1 kg) through aerobic conditioning. Since the weight loss, her menstrual cycles occur every 30 days. Her last menstrual period began 20 days prior to her visit with you.

On physical examination, her blood pressure is 115/72 mm Hg. Her height is 72 in (182.9 cm), and weight is 173 lb (78.6 kg) (BMI = 23.5 kg/m2). Her skin examination is notable for dark, coarse hair over the chin, maxilla, and lower stomach. She has no supraclavicular fat, galactorrhea, or violaceous striae. Her proximal muscle strength is normal.

Laboratory test results:

  • TSH = 1.3 mIU/L (0.5-5.0 mIU/L)
  • FSH = 2.4 mIU/mL (2.0-12.0 mIU/mL [follicular], 4.0-36.0 mIU/mL [midcycle], 1.0-9.0 mIU/mL [luteal]) (SI: 2.4 IU/L [2.0-12.0 IU/L, follicular], [4.0-36.0 IU/L, midcycle], [1.0-9.0 IU/L, luteal])
  • Prolactin = 5.2 ng/mL (4-30 ng/mL) (SI: 0.2 nmol/L [0.17-1.30 nmol/L])
  • Testosterone = 64 ng/dL (8-60 ng/dL) (SI: 2.2 nmol/L [0.3-2.1 nmol/L])
Which of the following diagnostic tests would be the most likely to determine the cause of infertility in this couple?

A. Transvaginal ultrasonography

B. Progesterone measurement

C. Estradiol measurement

D. Hysterosalpingogram

E. Semen analysis for her husband

Question 16

A 55-year-old man is referred for evaluation of his cardiovascular risk and for primary prevention. He does not smoke cigarettes, and he has hypertension controlled with lisinopril and diabetes mellitus controlled with metformin (hemoglobin A1c, 6.2% [44 mmol/mol]). His mother is alive and well in her early 80s; his father died in a motor vehicle crash at age 72 years. The patient has taken low-dosage aspirin daily since his mid-40s, as he heard it could reduce his risk of cardiovascular disease.

On physical examination, he appears healthy. His height is 71 in (180.3 cm), and weight is 202 lb (91.8 kg) (BMI = 28.2 kg/m2). His blood pressure is 138/81 mm Hg, and heart rate is 72 beats/min. Findings on examination are normal.

Laboratory test results (fasting):

  • Total cholesterol = 195 mg/dL (<200 mg/dL [optimal]) (SI: 5.05 mmol/L [<5.18 mmol/L])
  • LDL cholesterol = 97 mg/dL (<100 mg/dL [optimal]) (SI: 2.51 mmol/L [<2.59 mmol/L])
  • HDL cholesterol = 39 mg/dL (>60 mg/dL [optimal]) (SI: 1.01 mmol/L [>1.55 mmol/L])
  • Triglycerides = 295 mg/dL (<150 mg/dL [optimal]) (SI: 3.33 mmol/L [<3.88 mg/dL])
  • Non-HDL cholesterol = 156 mg/dL (<130 mg/dL [optimal]) (SI: 4.04 mmol/L [<3.37 mmol/L])
  • Fasting glucose = 96 mg/dL (70-99 mg/dL) (SI: 5.3 mmol/L [3.9-5.5 mmol/L])
Which of the following is the most appropriate therapy to lower this patient’s cardiovascular risk?
 

A. A statin

B. A fibrate

D. Ezetimibe

E. No treatment indicated

Question 17

A 41-year-old woman with a 12-year history of type 1 diabetes mellitus is planning to undergo an isolated pancreas transplant. She has always been highly adherent to therapy and her diabetes was most recently managed with an insulin pump. However, she had very volatile glucose readings and hypoglycemic unawareness prompting evaluation for transplant. She has early-stage chronic kidney disease, but not severe enough to indicate a renal transplant, and she has no evidence of macrovascular diabetes complications. She has proliferative retinopathy treated with laser therapy and some numbness in her feet.

Her family history is notable for osteoporosis with spinal fractures in her mother and a maternal aunt.

On physical examination, her blood pressure is 128/78 mm Hg. Her height is 64 in (162.6 cm), and weight is 142 lb (64.5 kg) (BMI = 24.4 kg/m2). She has diminished sensation to monofilament, but intact ankle reflexes.

Laboratory test results:

  • Hemoglobin A1c = 7.8% (4.0%-5.6%) (SI: 62 mmol/mol [20-38 mmol/mol])
  • Creatinine = 1.9 mg/dL (0.6-1.1 mg/dL) (SI: 168.0 µmol/L [53.0-97.2 µmol/L])
  • Urinary albumin-to-creatinine ratio = 98 mg/g creat (<17 mg/g creat [male])
  • Total cholesterol = 142 mg/dL (<200 mg/dL [optimal]) (SI: 3.68 mmol/L [<5.18 mmol/L])
  • LDL cholesterol = 81 mg/dL (<100 mg/dL [optimal]) (SI: 2.10 mmol/L [<0.59 mmol/L])
  • HDL cholesterol = 43 mg/dL (>60 mg/dL [optimal]) (SI: 1.11 mmol/L [>1.55 mmol/L])
  • Triglycerides = 90 mg/dL (<150 mg/dL [optimal]) (SI: 1.02 mmol/L [<3.88 mmol/L])
In addition to a reduction in hypoglycemia, which of the following outcomes can this patient expect following a successful pancreas transplant?
 

A. Reduced albuminuria

B. Reduced cardiovascular risk

C. Reduced osteoporosis risk

D. Regression of retinopathy

E. Recovery of peripheral sensation

Question 18

A 35-year-old man presents for evaluation of infertility. Secondary hypogonadism was diagnosed 6 years ago after he underwent hypophysectomy for a nonsecreting pituitary macroadenoma. Transdermal testosterone gel was initiated, and he has been doing well on this therapy. Now he desires a third child; he and his wife have been trying for a year without success. Multiple semen analyses have revealed oligospermia. He does not have any other relevant medical history. On physical examination, he is normally virilized. Testicular volume is 20 mL bilaterally.

Laboratory test results:

  • Testosterone = 612 ng/dL (300-900 ng/dL) (SI: 21.2 nmol/L [10.4-31.2 nmol/L])
  • LH = 0.8 mIU/mL (1.0-9.0 mIU/mL) (SI: 0.8 IU/L [1.0-9.0 IU/L])
  • FSH = 1.9 mIU/mL (1.0-13.0 mIU/mL) (SI: 1.1 IU/L [1.0-13.0 IU/L])
After stopping testosterone therapy, which of the following is the most appropriate initial treatment option for fertility induction in this patient?

A. Aromatase inhibitor

B. Subcutaneous GnRH pump

C. hCG injections

D. hCG and FSH injections

E. Clomiphene citrate

Question 19

A 68-year-old man with Graves disease is treated with radioiodine therapy. Two months later, his free T4 concentration is 0.65 ng/dL (0.8-1.8 ng/dL [SI: 8.4 pmol/L (10.30-23.17 pmol/L)]) and his TSH concentration is 5.2 mIU/L (0.5-5.0 mIU/L). Levothyroxine is initiated at a dosage of 50 mcg daily. The following month, the patient notes recurrent palpitations, and the following laboratory test results are documented:

  • TSH = <0.01 mIU/L
  • Free T4 = 3.1 ng/dL (0.8-1.8 ng/dL) (SI: 39.9 pmol/L [10.30-23.17 pmol/L])
  • Total T3 = 350 ng/dL (70-200 ng/dL) (SI: 5.4 nmol/L [1.08-3.08 nmol/L])

Thyroid hormone therapy is stopped and 2 weeks later, his free T4 and total T3 levels remain elevated.

Which of the following is the best next step in this patient’s management?

A. Continued observation

B. Repeat treatment with radioiodine now

C. Initiation of prednisone

D. Reinitiation of levothyroxine at a reduced dosage

E. Initiation of methimazole

Question 20

An 18-year-old man is referred to you because bilateral adrenal masses were identified on abdominal CT performed to evaluate intermittent abdominal pain (see image).

Axial view of abdominal CT. Bilateral adrenal masses (arrows) are documented with density values of 28 to 42 Hounsfield units.

He has no notable medical history and is unaware of any relevant family history. Physical examination findings and general appearance are normal. His resting pulse rate is 88 beats/min, and blood pressure is 142/95 mm Hg (supine) and 112/78 mm Hg (standing). His height is 72 in (182.9 cm), and weight is 185 lb (84.1 kg) (BMI = 25.1 kg/m2).

Laboratory test results:

  • Serum aldosterone = 14 ng/dL (1-21 ng/dL) (SI: 388.4 pmol/L [27.7-582.5 pmol/L])
  • Plasma renin activity = 2.4 ng/mL per h (0.6-4.3 ng/mL per h)
  • Serum cortisol after overnight 1-mg dexamethasone suppression test = 0.9 ?g/dL (SI: 24.8 nmol/L)
  • Serum calcium = 8.9 mg/dL (8.2-10.2 mg/dL) (SI: 2.2 mmol/L [2.1-2.6 mmol/L])
  • Urinary catecholamines:
    • Epinephrine = 21 µg/24 h (<35 µg/24 h) (SI: 114.5 nmol/d [<191 nmol/d])
    • Norepinephrine = 1425 µg/24 h (<170 µg/24 h) (SI: 8427.5 nmol/d [<1005 nmol/d])
  • Urinary metanephrines:
    • Metanephrine = 232 µg/24 h (<400 µg/24 h) (SI: 1176.2 nmol/d [<2028 nmol/d])
    • Normetanephrine = 3567 µg/24 h (<900 µg/24 h) (SI: 19,475.8 nmol/d [<4914 nmol/d])
Given his age, he is offered genetic screening. Which of the following genes is most likely to harbor a mutation?

A. RET proto-oncogene

B. NF1

C. MEN1

D.SDHD

E. VHL

Question 21

You are evaluating a 74-year-old woman in whom osteoporosis was diagnosed at age 67 years. She has since been treated with an oral bisphosphonate. She underwent menopause at age 53 years, and she has not taken estrogen. Results from a laboratory evaluation (including a complete blood cell count, chemistry panel, PTH level, 25-hydroxyvitamin D level, and 24-hour urinary calcium excretion) were normal 2 years ago and again last month. Eight years ago, breast cancer was diagnosed, and she was treated with surgery, chemotherapy, and radiation followed by the use of an aromatase inhibitor that she still takes. Over the past 2 years, her bone mineral density has decreased. She has lost 2 in (5.1 cm) in height. Vertebral fracture assessment shows 2 thoracic compression fractures of uncertain age. The patient asks about treatment with teriparatide.

Which of the following is a contraindication to the use of teriparatide in this patient?

A. Her age

B. History of breast cancer

C. Previous bisphosphonate therapy

D. History of radiation treatment

E. Concurrent treatment with an aromatase inhibitor

Question 22

A 47-year-old woman presents for follow-up. She has a family history of type 2 diabetes mellitus. Six months ago, impaired fasting glucose was diagnosed and you referred her to a 12-week intensive lifestyle program that incorporated dietary advice, physical activity recommendations, and behavioral therapy. She completed the intensive lifestyle program and now participates in a monthly group weight management session. She tracks her food intake and is mindful of triggers that promote overeating. She does not participate in an exercise program, although she tries to walk a few times each week. She weighs herself at least once weekly. She also has a history of hypertension, which is currently treated with lisinopril, 10 mg daily.

On physical examination, her blood pressure is 130/80 mm Hg and pulse rate is 78 beats/min. Her height is 64 in (162.5 cm). Six months ago, she weighed 196 lb (89.1 kg) (BMI = 33.6 kg/m2). Today, she weighs 181.5 lb (82.5 kg) (BMI = 31.2 kg/m2). Examination findings are otherwise unremarkable.

You commend her on her weight loss. However, you worry that this patient is at high risk of weight regain because:

A. She has no regular exercise program

B. She has experienced insufficient weight loss given her efforts

C. Her monthly group meeting provides inadequate support

D. Her weight monitoring is too infrequent

E. The intensive lifestyle program was too short

Question 23

A 65-year-old man is referred to you for evaluation of possible Paget disease. He was found to have an elevated alkaline phosphatase level on recent laboratory studies done before cataract surgery. He had bariatric surgery 15 years ago and takes cholecalciferol, 2000 IU daily. He has no chronic medical problems and has not been to a physician in the past 5 years. Generally, he feels well.

Laboratory test results:

  • Alkaline phosphatase = 220 U/L (50-120 U/L) (SI: 3.7 µkat/L [0.8-2.0 µkat/L])
  • Serum calcium = 8.6 mg/dL (8.2-10.2 mg/dL) (SI: 2.2 mmol/L [2.1-2.6 mmol/L])
  • Serum creatinine = 1.3 mg/dL (0.7-1.3 mg/dL) (SI: 114.9 µmol/L [61.9-114.9 µmol/L])
  • Gamma-glutamyltranspeptidase, normal
Which of the following should be the next step in this patient’s care?

A. Whole-body bone scan

B. Skeletal survey

C. Intravenous zoledronic acid infusion

D. Serum C-telopeptide measurement

E. 25-Hydroxyvitamin D and PTH measurement

Question 24

A 48-year-old man in whom type 2 diabetes mellitus was diagnosed 6 years ago presents for recommendations on how to best reduce his cardiovascular disease risk. His diabetes has been complicated by background retinopathy. He has no history of hyperlipidemia, but his internist prescribed a statin for cardiovascular protection. He follows a low-fat, carbohydrate-moderated, high-fiber diet and he walks 30 minutes 3 to 4 days per week. He does not smoke cigarettes. He does not have a personal or family history of early cardiovascular disease. He has no exertional chest pain or leg claudication.

His current medications are atorvastatin, 20 mg daily; metformin, 1000 mg twice daily; and glimepiride, 4 mg daily.

On physical examination, his height is 72 in (182.9 cm) and weight is 188 lb (85.5 kg) (BMI = 25.5 kg/m2). His blood pressure is 131/76 mm Hg, and pulse rate is 84 beats/min. He has no jugular venous distention, and examination findings of his heart, lungs, abdomen, extremities, and pulses are normal. There are no carotid bruits.

Findings from an electrocardiogram are normal.

Laboratory test results:

  • Hemoglobin A1c = 7.3% (4.0%-5.6%) (56 mmol/mol [20-38 mmol/mol])
  • Total cholesterol = 143 mg/dL (<200 mg/dL [optimal]) (SI: 3.70 mmol/L [<5.18 mmol/L])
  • LDL cholesterol = 68 mg/dL (<100 mg/dL [optimal]) (SI: 1.76 mmol/L [<2.59 mmol/L])
  • HDL cholesterol = 46 mg/dL (>60 mg/dL [optimal]) (SI: 1.19 mmol/L [>1.55 mmol/L])
  • Triglycerides = 139 mg/dL (<150 mg/dL [optimal]) (SI: 1.57 mmol/L [<3.88 mmol/L])
  • Urinary albumin-to-creatinine ratio = 6 mg/g creat (<30 mg/g creat)
Which of the following do you recommend to reduce his cardiovascular risk?

A. Initiate low-dosage aspirin

B. Initiate clopidogrel

C. Initiate an ACE inhibitor

D. Initiate empagliflozin

E. No changes to his current medications

Question 25

A 73-year-old man on testosterone therapy returns to clinic for follow-up. He was first seen 8 months ago with concerns of reduced libido and fatigue. At that visit, his morning total testosterone level was 225 ng/dL (7.8 nmol/L) and his prostate-specific antigen level was 1.3 ng/mL (1.3 µg/L). His prostate was symmetrically enlarged without nodules.

After thorough evaluation, the testosterone patch, 4 mg daily, was prescribed, which he has been taking for 6 months. The patient feels well on testosterone therapy and reports improved sexual function and energy. He has no lower urinary tract symptoms.

On physical examination at today’s appointment, his prostate examination is unchanged.

Laboratory test results:

  • Testosterone = 451 ng/dL (300-900 ng/dL) (SI: 15.6 nmol/L [10.4-31.2 nmol/L])
  • Prostate-specific antigen = 3.1 ng/mL (<7.0 ng/mL) (SI: 3.1 µg/L [<7.0 µg/L])
  • Repeated prostate-specific antigen = 2.9 ng/mL (SI: 2.9 µg/L)
Which of the following is the best next step in this patient’s management?
 

A. Refer him to a urologist

B. Provide reassurance and schedule a follow-up appointment in 6 months

C. Decrease the dosage of the testosterone patch to 2 mg daily

D. Start a 5?-reductase inhibitor

E. Change to intramuscular administration with testosterone enanthate

Question 26

A 33-year-old man has been referred to you for evaluation of Cushing syndrome. He has an 11-year history of HIV infection. He is taking antiretroviral therapy, including didanosine, tenofovir, and ritonavir. His viral load is zero and his CD4 cell count is normal. He has developed asthma in the past 6 months and has been taking fluticasone/salmeterol twice daily and an albuterol metered-dose inhaler as needed. He has gained 30 lb (13.6 kg) in the past 3 months. Hypertension and fasting hyperglycemia have developed.

On physical examination, he has a very cushingoid appearance, with wide, violaceous abdominal striae and proximal muscle weakness.

Which of the following laboratory profiles is most likely to be found in this man?

Answer

Plasma ACTH

DHEA-S

Cortisol

A.

Normal

Normal

Normal

B.

C.

D.

E.

A. A

B. B

C. C

D. D

E. E

Question 27

A 63-year-old woman is being treated for a nonthyroid cancer.

Laboratory test results before treatment initiation:

  • TSH = 2.14 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 1.3 ng/dL (0.8-1.8 ng/dL) (SI: 16.3 pmol/L [10.30-23.17 pmol/L])

Ten weeks after starting the cancer therapy, she reports fatigue, constipation, and cold intolerance. Results from repeated thyroid function tests document a TSH concentration of 42 mIU/L and a free T4 concentration of 0.5 ng/dL (6.4 pmol/L).

Which of the following medications is the most likely cause of her thyroid dysfunction?

A. Sunitinib

B. Denileukin diftitox

C. Bexarotene

D. Ipilimumab

E. Tamoxifen

Question 28

A 27-year-old woman presents with a 6-month history of amenorrhea. She has been in excellent health except for a history of hypothyroidism due to Hashimoto thyroiditis. She has been euthyroid while taking levothyroxine, 100 mcg daily. She reports mild acne, vaginal dryness, and night sweats.

Physical examination is notable for a small thyroid gland.

Initial laboratory test results:

  • TSH = 3.0 mIU/L (0.5-5.0 mIU/L)
  • Estradiol = <20 pg/mL (SI: <73.4 pmol/L)
  • FSH = 93.6 mIU/mL (2.0-12.0 mIU/mL [follicular], 4.0-36.0 mIU/mL [midcycle], 1.0-9.0 mIU/mL [luteal]) (SI: 93.6 IU/L [2.0-12.0 IU/L, follicular], [4.0-36.0 IU/L, midcycle], [1.0-9.0 IU/L, luteal])
  • Prolactin = 6.7 ng/mL (4-30 ng/mL) (SI: 0.29 nmol/L [0.17-1.30 nmol/L])
  • ?-hCG, undetectable
Which of the following would be the most appropriate next test?

A. LH measurement

B. Pituitary MRI

C. Antinuclear antibody measurement

D. Ovarian antibody measurement

E. Karyotype analysis

Question 29

A 52-year-old woman with familial hypercholesterolemia has been treated with rosuvastatin, 40 mg daily, and ezetimibe, 10 mg daily, for the past 5 years. This combination has reduced her total cholesterol concentration from 385 to 215 mg/dL (9.97 to 5.57 mmol/L) and her LDL-cholesterol concentration from 300 to 120 mg/dL (7.77 to 3.11 mmol/L). For the past 2 months, she has had muscle aches, fatigue, and constipation. She now presents with a total cholesterol concentration of 260 mg/dL (6.73 mmol/L) and reports muscle pains. Creatine phosphokinase and blood glucose levels are not elevated.

Measuring which of the following would be most useful now?

A. AST and ALT

B. 8-AM cortisol

C. TSH

D. Urinary protein

E. Urinary myoglobin

Question 30

A 55-year-old white woman underwent menopause 3 years ago and she has no menopausal symptoms. Her BMI is 20 kg/m2. She is generally healthy, but she fractured 2 fingers after a minor fall 2 years ago. She does not smoke cigarettes, she drinks 1 glass of wine nightly, and she takes no medications. Her diet provides 1200 mg of calcium daily and 1000 IU of vitamin D daily. Her mother had a hip fracture.

The patient’s DXA documents the following:

Site

BMD, g/cm2

T Score

Total hip

0.698

–1.5

Femoral neck

0.658

–1.7

L1-L4

0.983

–0.3


Vertebral fracture assessment does not identify any compression fractures. Her FRAX 10-year risk is 12% for any major osteoporotic fracture and 0.7% for hip fracture.

Which of the following is the best management plan?

A. Start a bisphosphonate and perform DXA in 1 year

B. Continue dietary calcium and vitamin D and perform DXA in 2 years

C. Start raloxifene and perform DXA in 1 year

D. Start estrogen replacement therapy

E. Start teriparatide and perform DXA in 1 year

Question 31

A 19-year-old man with type 1 diabetes mellitus reports a 6-month history of diarrhea, unintentional weight loss, poor glycemic control, and a rash. On physical examination, he has no abdominal tenderness, a normal 10-g monofilament test, and a rash that is characterized by erythematous, papular, small and large blisters that burn and itch intensely.

Which of the following is the best initial approach to evaluate his symptoms?

A. Colonoscopy

B. Upper gastrointestinal series with small-bowel follow-through

C. Serum gastrin measurement

D. Tissue transglutaminase and/or deaminated gliadin antibody assessment

E. Skin biopsy

Question 32

A 24-year-old man is noted to have a goiter and is referred for further evaluation. The patient’s medical history is otherwise unremarkable. On physical examination, his pulse rate is 90 beats/min. He has a diffuse goiter, twice normal size, without nodule or bruit. Deep tendon reflexes are normal and he has no tremor.

Laboratory test results:

  • Free T4 = 2.7 ng/dL (0.8-1.8 ng/dL) (SI: 34.8 pmol/L [10.3-23.2 pmol/L])
  • Total T3 = 300 ng/dL (70-200 ng/dL) (SI: 4.6 nmol/L [1.1-3.1 nmol/L])
  • TSH = 3.8 mIU/L (0.5-5.0 mIU/L) (TSH is measured in 2 other commercial laboratories with similar results)
  • ?-subunit = 0.3 ng/mL (<1.2 ng/mL) (SI: 0.3 µg/L [<1.2 µg/L])

MRI of the pituitary is normal.

Which of the following is the most likely explanation?

A. Thyroid hormone resistance

B. A TSH-producing pituitary adenoma

C. Heterophilic antibody interference with the TSH assay

D. T4 antibody interference with the free T4 assay

E. Surreptitious use of thyroid hormone

Question 33

A 39-year-old obese man is referred after a fingerstick blood glucose measurement at a health screening fair at work was documented to be 178 mg/dL (9.9 mmol/L). He had recently eaten lunch. His medical history is notable for dyslipidemia that is well controlled on simvastatin, gout, and obesity.

On physical examination, his blood pressure is 132/78 mm Hg and his BMI is 41.5 kg/m2. Acanthosis nigricans is present, but there are no other notable findings on physical examination.

You reassess his glycemic status:

  • Fasting plasma glucose (laboratory) = 119 mg/dL (70-99 mg/dL) (SI: 6.6 mmol/L [3.9-5.5 mmol/L])
  • Hemoglobin A1c = 6.6% (4.0%-5.6%) (SI: 49 mmol/mol [20-38 mmol/mol])

Repeated sampling 1 week later:

  • Fasting plasma glucose = 107 mg/dL (5.9 mmol/L)
  • Hemoglobin A1c = 6.8% (51 mmol/mol)
Which of the following diagnoses does this patient have?
 

A. Normal glucose tolerance

B. Prediabetes

C. Impaired glucose tolerance

D. Impaired fasting glucose

E. Type 2 diabetes mellitus

Question 34

A 42-year-old woman presents for her annual thyroid check. She has a history of Graves disease treated with radioactive iodine, and she has been on a stable dosage of thyroid hormone supplementation for the past 6 years. In the last 12 months, hypertension and tension headaches were diagnosed. Her blood pressure is now controlled with metoprolol, and a gradual titration of amitriptyline has helped her headaches. Her main concerns relate to her weight. Over the past year, she has gained 20 lb (9.1 kg). She worries that her thyroid hormone dosage is inadequate.

Her current medications are levothyroxine, 100 mcg daily; metoprolol, 100 mg daily; cetirizine, 10 mg daily (for seasonal allergies); amitriptyline, 75 mg daily; and naproxen (as needed for headaches).

Her TSH concentration is 2.4 mIU/L (0.5-5.0 mIU/L).

On physical examination, her height is 65 in (165 cm) and weight is 173.5 lb (78.9 kg) (BMI = 28.9 kg/m2). Her thyroid gland is not palpable. The rest of her examination findings are unremarkable.

In addition to discussing efforts at lifestyle changes to help manage her weight, which of the following medications should you consider to be the most important factor contributing to her weight gain?

A. Amitriptyline

B. Inadequate levothyroxine

C. Metoprolol

D. Cetirizine

E. Naproxen

Question 35

A 38-year-old man presents with asymptomatic hypercalcemia. He has normal findings on physical examination and the following laboratory workup:

  • Total calcium = 11.5 mg/dL (8.2-10.2 mg/dL) (SI: 2.9 mmol/L [2.1-2.6 mmol/L])
  • PTH = 50 pg/mL (10-65 pg/mL) (SI: 50 ng/L [10-65 ng/L])
  • Creatinine = 1.1 mg/dL (0.7-1.3 mg/dL) (SI: 97.2 µmol/L [61.9-114.9 µmol/L])
  • 25-Hydroxyvitamin D = 22 ng/mL (25-80 ng/mL [optimal]) (SI: 54.9 nmol/L [62.4-199.7 nmol/L])
  • Magnesium = 3.0 mg/dL (1.5-2.3 mg/dL) (SI: 1.2 mmol/L [0.6-0.9 mmol/L])

Urinary calcium excretion is 36 mg/24 h with a calcium-to-creatinine clearance ratio of 0.01. Neck ultrasonography does not identify an enlarged parathyroid gland. There are no previous calcium values for comparison. The patient is adopted and has no knowledge of his family’s medical history.

He undergoes parathyroidectomy, and 2 enlarged glands are resected. However, intraoperative PTH levels remain elevated. Pathologic examination reveals hyperplasia in both glands. Postoperatively, his calcium concentration is 11.6 mg/dL (2.9 mmol/L). On repeated testing 8 months postoperatively, he continues to have hypercalcemia and a PTH concentration in the upper-normal range.

Which of the following is the best next step in this patient’s care?

A. Start cinacalcet, 30 mg daily

B. Perform a second surgery with biopsy and resection of both remaining parathyroid glands

C. Perform genetic testing

D. Perform a 4D CT of the neck

E. Perform neck ultrasonography again

Question 36

A 55-year-old woman is receiving adjuvant mitotane therapy after left adrenalectomy for a 6-cm adrenocortical cancer. She takes 1 g 4 times daily, and her last serum mitotane value was therapeutic at 15 mg/L. She also takes hydrocortisone, 60 mg on upon waking in the morning and 30 mg in the midafternoon. A serum cortisol level 4 hours after the morning dose is 7 ?g/dL (193.1 nmol/L).

Which of the following mechanisms explains the need for higher hydrocortisone dosages in this patient?

A. Decreased corticosteroid-binding globulin

B. Induced hepatic CYP3A4 activity

C. Impaired cortisol absorption

D. Increased urinary cortisol excretion

E. Increased 5?-reductase activity

Question 37

A 62-year-old man is referred by his primary care physician to discuss management of erectile dysfunction in the setting of normal libido. The patient has a medical history of longstanding hypertension that has been well controlled. In his late 50s, he had a positive nuclear stress test. A subsequent coronary angiogram showed several stenotic lesions, and 2 stents were placed. His current medications include low-dosage aspirin, atorvastatin, lisinopril, metoprolol, and a multivitamin. The patient is married and has fathered 2 children. He plays tennis 3 times weekly without any chest pain.

On physical examination, the patient appears comfortable. His height is 71 in (180.3 cm), and weight is 195 lb (88.6 kg) (BMI = 27.2 kg/m2). His blood pressure is 126/82 mm Hg, and pulse rate is 71 beats/min. His physical examination findings are unremarkable, including those from cardiac and genital examinations. He has trace lower-extremity edema.

Laboratory test results (afternoon):

  • Complete blood cell count, normal
  • TSH = 2.6 mIU/L (0.5-5.0 mIU/L)
  • Total testosterone = 290 ng/dL (300-900 ng/dL) (SI: 10.1 nmol/L [10.4-31.2 nmol/L])
  • 25-Hydroxyvitamin D = 27 ng/mL (25-80 ng/mL) (SI: 67.4 nmol/L [62.4-199.7 nmol/L])
Which of the following therapies would be best?

A. Testosterone enanthate intramuscular injections every 2 weeks

B. Transdermal testosterone gel applied daily

C. Tadalafil, 10 mg 1 hour before sexual activity

D. Alprostadil urethral suppository as needed for sexual activity

E. Penile implant performed by a urologist

Question 38

A 30-year-old woman presents for evaluation of hypercalcemia after workup for a 6-month history of worsening fatigue and anorexia documented a serum calcium concentration of 12.9 mg/dL (3.2 mmol/L). During her summer vacation at the beach, she became so dehydrated that she required intravenous hydration at a local emergency department. She reports poor sleep because she gets up multiple times to urinate. Menses have become irregular and she has not had a period for 2 months. She notes constipation, dry skin, hair loss, and a 10-lb (4.5-kg) weight loss. She has no night sweats. She has had no fractures. She has no history of kidney stones, but she recalls an episode of hematuria. She has no family history of hypercalcemia or other endocrine disorders. Other than a daily multivitamin, she takes no medication.

On physical examination, she appears fatigued. While sitting, her pulse rate is 80 beats/min and blood pressure is 105/70 mm Hg. While standing, her pulse rate is 100 beats/min and blood pressure is 90/65 mm Hg. Her temperature is 97.7ºF (36.5ºC). Her height is 64 in (162.6 cm), and weight is 137 lb (62.3 kg) (BMI = 23.5 kg/m2). Mucous membranes are dry, periorbital edema is present, and visual fields are intact. Findings on thyroid examination are normal. She has expressible galactorrhea. She has no organomegaly. You observe no rashes or hyperpigmentation, but her skin is dry and there is some tenting of the skin. Muscle bulk, tone, and strength are normal, but her deep tendon reflexes are delayed.

Laboratory test results:

  • Sodium = 129 mEq/L (136-142 mEq/L) (SI: 129 mmol/L [136-142 mmol/L])
  • Potassium = 4.0 mEq/L (3.5-5.0 mEq/L) (SI: 4.0 mmol/L [3.5-5.0 mmol/L])
  • Creatinine = 1.3 mg/dL (0.6-1.1 mg/dL) (SI: 114.9 µmol/L [53.0-97.2 µmol/L])
  • Serum urea nitrogen = 20 mg/dL (8-23 mg/dL) (SI: 7.1 mmol/L [2.9-8.2 mmol/L])
  • Hematocrit = 36% (41%-50%) (SI: 0.36 [0.41-0.51])
  • Calcium = 12.9 mg/dL (8.2-10.2 mg/dL) (SI: 3.2 mmol/L [2.1-2.6 mmol/L])
  • Phosphorus = 4.9 mg/dL (2.3-4.7 mg/dL) (SI: 1.6 mmol/L [0.7-1.5 mmol/L])
  • Intact PTH = 5 pg/mL (10-65 pg/mL) (SI: 5 ng/L [10-65 ng/L])
  • Prolactin = 42 ng/mL (4-30 ng/mL) (SI: 1.8 nmol/L [0.17-1.30 nmol/L])
  • TSH = 0.5 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 0.5 ng/dL (0.8-1.8 ng/dL) (SI: 6.4 pmol/L [10.30-23.17 pmol/L])
  • 25-Hydroxyvitamin D = 25 ng/mL (25-80 ng/mL [optimal]) (SI: 62.4 nmol/L [62.4-199.7 nmol/L])
  • 1,25-Hydroxyvitamin D = 85 pg/mL (16-65 pg/mL) (SI: 221 pmol/L [41.6-169.0 pmol/L])
  • Alkaline phosphatase = 98 U/L (50-120 U/L) (SI: 1.6 µkat/L [0.84-2.00 µkat/L])
  • FSH = 0.1 mIU/mL (4.0-36.0 mIU/mL) (SI: 0.1 IU/L [4.0-36.0 IU/L])
Which of the following medications should be prescribed initially?

A. Zoledronic acid

B. Cinacalcet

C. Calcitonin

D. Prednisone

E. Levothyroxine

Question 39

A 69-year-old man with interstitial pulmonary fibrosis is admitted to the hospital with respiratory failure and possible bacterial pneumonia requiring endotracheal intubation and admission to the intensive care unit. Medical history includes chronic obstructive pulmonary disease, right-sided heart failure, hypertension, and hypothyroidism. There is no history of diabetes and no record of glucose-lowering medication use in his chart. At presentation, his random blood glucose level is documented to be 183 mg/dL (10.2 mmol/L). After treatment initiation with methylprednisolone, his blood glucose climbs to 302 mg/dL (16.8 mmol/L).

Which of the following is the best approach to manage this patient’s hyperglycemia?

A. Human regular insulin subcutaneously every 4 hours, adjusted to maintain blood glucose greater than 180 mg/dL (10.0 mmol/L)

B. Intravenous human regular insulin infusion titrated to achieve blood glucose between 140 and 180 mg/dL (7.8-10.0 mmol/L)

C. Intravenous human regular insulin infusion titrated to achieve blood glucose between 80 and 110 mg/dL (4.4-6.1 mmol/L)

D. Daily insulin glargine plus insulin aspart subcutaneously every 6 hours, adjusted to a target blood glucose between 140 and 180 mg/dL (7.8-10.0 mmol/L)

E. Subcutaneous sliding scale insulin to determine his insulin requirements

Question 40

A 27-year-old pregnant woman seeks your advice at 6 weeks’ gestation. This is her first pregnancy. She has salt-wasting congenital adrenal hyperplasia due to 21-hydroxylase deficiency, for which she takes hydrocortisone and fludrocortisone. She is concerned that her baby may have the same condition.

Which of the following is the best next step in this patient’s management?

A. Measure serum 17-hydroxyprogesterone

B. Add dexamethasone, 0.5 mg at bedtime

C. Obtain fetal DNA via chorionic villus sampling for CYP21A2 mutation analysis

D. Perform amniocentesis to determine fetal sex

E. Perform molecular genetic testing for CYP21A2 mutations in the father

Question 41

A 56-year-old woman presents with increased pain in her right hip, right groin, and left tibia, which has been limiting her mobility. Paget disease of bone was diagnosed at age 34 years when an elevated alkaline phosphatase level was documented on routine blood testing performed because of a family history of Paget disease in her mother and multiple maternal relatives. Since diagnosis, she has received a 7-year course of intermittent treatment with bisphosphonate therapy. She is an 80 pack-year active cigarette smoker with chronic obstructive lung disease, and she also has a history of severe gastroesophageal reflux disease. She has had no fractures, loss of height, diminished hearing, or neuropathy.

On physical examination, she appears older than her stated age and has a hoarse voice. She has some discoloration of her teeth with no gingivitis or exposed bone. There is no frontal bossing. She has asymmetry of her left tibia compared with the right tibia with some irregular protrusion and increased warmth overlying the skin of the left tibia. The right pelvic brim has no palpable abnormalities.

Laboratory test results:

  • Alkaline phosphatase = 200 U/L (50-120 U/L) (SI: 3.3 µkat/L [0.84-2.00 µkat/L])
  • Bone-specific alkaline phosphatase = 114 µg/L (?22 µg/L)
  • Calcium = 9.4 mg/dL (8.2-10.2 mg/dL) (SI: 2.4 mmol/L [2.1-2.6 mmol/L])
  • Phosphorus = 3.3 mg/dL (2.3-4.7 mg/dL) (SI: 1.1 mmol/L [0.7-1.5 mmol/L])
  • Albumin = 4.3 g/dL (3.5-5.0 g/dL) (SI: 43 g/L [35-50 g/L])
  • Creatinine = 0.8 mg/dL (0.6-1.1 mg/dL) (SI: 70.7 µmol/L [53.0-97.2 µmol/L])
  • 25-Hydroxyvitamin D = 18 ng/mL (25-80 ng/mL [optimal]) (SI: 44.9 nmol/L [62.4-199.7 nmol/L])

Imaging results are shown (see images).

Bone scan.

Plain x-rays of the left tibia (left panel, lateral view; right panel, anteroposterior view).

Plain x-ray of the pelvis (anteroposterior view).

Which of the following is the most appropriate next step in this patient’s management?

A. Administer denosumab, 60 mg subcutaneously (1 dose)

B. Administer zoledronic acid, 5 mg intravenously (1 dose)

C. Prescribe ergocalciferol, 50,000 IU orally weekly for 8 weeks

D. Prescribe risedronate, 30 mg daily for 2 months

E. Nothing now; she is at risk for osteonecrosis of the jaw

Question 42

A 38-year-old woman is referred for evaluation of hypoglycemia. The patient has had overwhelming fatigue associated with tachycardia, sweating, and tremor that occur throughout the day. These episodes have no clear association with food intake, but they seem to be precipitated by exertion. Thus, she is admitted for a 72-hour supervised fast. This proceeds uneventfully until the 60th hour when, at 1:00 AM, a reflectance meter glucose concentration obtained by fingerstick is 45 mg/dL (2.5 mmol/L). The patient is subsequently awoken from sleep and asked about accompanying symptoms. She reports the presence of her usual symptoms. End-of-fast procedures are commenced.

Laboratory values are shown:

  • Glucose = 51 mg/dL (70-99 mg/dL (SI: 2.8 mmol/L [3.9-5.5 mmol/L])
  • Insulin = <0.1 µIU/mL (1.4-14.0 µIU/mL) (SI: <0.7 pmol/L [9.7-97.2 pmol/L])
  • Proinsulin = 26.5 pg/mL (26.5-176.4 pg/mL) (SI: 3.0 pmol/L [3.0-20.0 pmol/L])
  • C-peptide = <0.1 ng/mL (0.9-4.3 ng/mL) (SI: <0.03 nmol/L [0.30-1.42 nmol/L])
  • ?-Hydroxybutyrate = 77.0 mg/dL (<3.0 mg/dL) (SI: 7400 µmol/L [<300 µmol/L])

Administration of glucagon results in the following glycemic response:

Measurement

Time From End of Fast, min

0

10

20

30

Glucose

52 mg/dL
(2.9 mmol/L)

57 mg/dL
(3.2 mmol/L)

55 mg/dL
(3.1 mmol/L)

54 mg/dL
(3.0 mmol/L)

You conclude that the data:

A. Cannot be interpreted because the glucose level at the time the fast was ended was not low enough; the fast must be repeated

B. Are compatible with non–insulin-mediated hypoglycemia; an ACTH stimulation test is indicated

C. Are compatible with a normal fast; the Whipple triad has not been fulfilled

D. Are compatible with an insulinlike factor mediating hypoglycemia; IGF-2 measurement is indicated

E. Are compatible with insulin-mediated hypoglycemia; the sample tubes should be assessed for hemolysis, which would explain the low concentrations of ?-cell polypeptides

Question 43

A 28-year-old man undergoes thyroidectomy with central neck dissection for a 2.5-cm papillary thyroid cancer. The tumor shows microscopic local invasion but no aggressive histology and 1 of 12 central lymph nodes contains tumor. The patient undergoes radioiodine remnant ablation using 100 mCi of 131I, and the posttreatment scan shows no uptake outside of the thyroid bed. Surveillance testing at 6 months reveals a stimulated thyroglobulin concentration of 15 ng/mL (15 µg/L) with negative thyroglobulin antibodies, no abnormal uptake on radioiodine whole-body scan, and no adenopathy on neck ultrasonography. No additional therapy is given. Six months later, a suppressed thyroglobulin level is 0.5 ng/mL (0.5 µg/L), stimulated thyroglobulin is 5 ng/mL (5 µg/L), thyroglobulin antibodies are negative, and neck ultrasonography is unchanged.

Which of the following should be the next step in this patient’s management?

A. Thyroglobulin testing using a different assay

B. PET-CT scan

C. CT of the chest

D. MRI of the neck

E. Repeated surveillance testing in 1 year

Question 44

You are asked to see a 27-year-old, 46,XX individual who identifies as male and carries a diagnosis of gender dysphoria. He has undergone psychotherapy, has lived as a man for the last year and feels comfortable with his decision. He also has a good support network. He now seeks further treatment to assist with virilization.

His medical history is unremarkable. He has no family history of cardiovascular disease, breast, or ovarian cancer. He smokes one-half pack of cigarettes per day and drinks 11 alcoholic beverages per week.

On physical examination, his blood pressure is 109/72 mm Hg. His height is 66 in (167.6 cm), and weight is 146 lb (66.4 kg) (BMI = 23.6 kg/m2). He has hair on the upper lip and below the umbilicus. Breasts are without masses and findings on gynecologic examination are normal.

Laboratory test results:

  • Liver function, normal
  • Hematocrit = 35% (35%-45%) (SI: 0.35 [0.35-0.45])
  • Total cholesterol = 195 mg/dL (<200 mg/dL [optimal]) (SI: 5.05 mmol/L [<5.18 mmol/L])
  • Triglycerides = 84 mg/dL (<150 mg/dL [optimal]) (SI: 0.95 mmol/L [<3.88 mmol/L])
  • HDL cholesterol = 37 mg/dL (>60 mg/dL [optimal]) (SI: 0.96 mmol/L [>1.55 mmol/L])
  • LDL cholesterol = 104 mg/dL (<100 mg/dL [optimal]) (SI: 2.69 mmol/L [<2.59 mmol/L])
  • Hemoglobin A1c = 5.0% (4.0%-5.6%) (31 mmol/mol [20-38 mmol/mol])
  • Estradiol = 75 pg/mL (17-200 pg/mL) (SI: 275.5 pmol/L [62.9-739.6 pmol/L])
Which of the following is the best next step in his care plan?

A. Oophorectomy

B. Testosterone therapy

C. Aromatase inhibitor therapy

D. Testosterone plus aromatase inhibitor therapy

E. GnRH analogue therapy

Question 45

A 65-year-old woman presents with a 4-month history of fatigue, weight loss (25 lb [11.4 kg]), frequent headache, and nausea. She reports no visual symptoms, acral enlargement, increased thirst, or frequent urination. Her medical history is notable for dyslipidemia and knee osteoarthritis. Medications include atorvastatin and acetaminophen.

On physical examination, her blood pressure is 105/60 mm Hg and pulse rate is 78 beats/min. Her height is 67 in (170.2 cm), and weight is 156 lb (70.9 kg) (BMI = 24.4 kg/m2). Visual fields are intact on perimetry. There are no clinical features suggestive of GH or cortisol excess.

Laboratory test results:

  • Sodium = 135 mEq/L (136-142 mEq/L) (SI: 135 mmol/L [136-142 mmol/L])
  • Cortisol (8 AM) = 2.1 µg/dL (5-25 ?g/dL) (SI: 57.9 nmol/L [137.9-689.7 nmol/L])
  • Prolactin = 29 ng/mL (4-30 ng/mL) (SI: 1.3 nmol/L [0.17-1.30 nmol/L])
  • TSH = 1.6 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 0.6 ng/dL (0.8-1.8 ng/dL) (SI: 7.8 pmol/L [10.30-23.17 pmol/L])
  • FSH = 1.0 mIU/mL (>30 mIU/mL) (SI: 1.0 IU/L [>30 IU/L])
  • LH = 2.1 mIU/mL (>30 mIU/mL) (SI: 2.1 IU/L [>30 IU/L])

Brain MRI shows a cystic sellar mass displacing the optic chiasm (see image, left panel).

She begins hydrocortisone and levothyroxine replacement and undergoes transsphenoidal drainage of the lesion. Pathologic findings are consistent with Rathke cleft cyst with squamous metaplasia. Early postoperative MRI shows decompression and collapse of the cyst. Six months later, she develops recurrent headache. Follow-up MRI shows reexpansion of the cyst. She undergoes a second transsphenoidal procedure to drain the lesion. However, she develops recurrent headache and the cyst re-expands 3 months later. She undergoes a third transsphenoidal operation to drain the lesion, following which the cyst remains unchanged (see image, right panel).

Which of the following should you recommend now?

A. Observation

B. Lanreotide depot therapy

C. Radiation therapy to the sella

D. Craniotomy and cyst fenestration

E. Cabergoline therapy

Question 46

A 51-year-old man comes to see you for a second opinion about his cholesterol. He had a recent hospital admission for chest pain, and a coronary stent was placed. His father died of a myocardial infarction at age 49 years (he smoked 2 packs of cigarettes per day), and his brother developed angina at age 52 years. Four years ago, his primary care physician prescribed atorvastatin, 40 mg daily, for an LDL-cholesterol level of 135 mg/dL (3.50 mmol/L). His LDL-cholesterol level is now 90 mg/dL (2.33 mmol/L), and his triglyceride level is 210 mg/dL (2.37 mmol/L). His primary care physician says that he does not need any more medication. However, given his recent hospitalization, the patient thinks his LDL-cholesterol level should be lower and he comes to you for a second opinion.

Which of the following should be added as the best next step?

A. Ezetimibe

B. Fenofibrate

C. Niacin

D. Cholestyramine

E. Omega-3 fatty acids

Question 47

A 66-year-old woman presents as a new patient to your practice because of her concerns after seeing an optometrist. She has a 14-year history of type 2 diabetes mellitus. She has had poor follow-up with providers in recent years, but has managed to continue her medications (metformin, glyburide, and lovastatin) with variable adherence to her treatment regimen. She has not experienced any notable vision-related symptoms. Her blood pressure is 132/84 mm Hg.

She shows you the retinal photograph from her recent optometry examination.

Laboratory test results:

  • Hemoglobin A1c = 8.0% (4.0%-5.6%) (64 mmol/mol [20-38 mmol/mol])
Given the photograph in the context of her presentation, which of the following should you recommend?

A. Intensification of therapy to reduce her hemoglobin A1c level to less than 7.0% (&lt;53 mmol/mol) and routine referral to an ophthalmologist

B. Immediate referral to an ophthalmologist for probable focal laser/intravitreal antivascular endothelial growth factor therapy

C. Addition of pioglitazone and recommendation that the patient follow-up with an ophthalmologist in 6 to 12 months

D. Expedited referral to an ophthalmologist for panretinal photocoagulation

E. Addition of lisinopril and basal insulin and routine referral to an ophthalmologist

Question 48

A 28-year-old woman in her 20th week of pregnancy is referred to you because of new-onset hypertension and hypokalemia. Before pregnancy she had mild hypertension, which was well controlled with a single agent. However, since she has entered her second trimester, the hypertension has become more difficult to control and her serum potassium levels have been low. Her medications include methyldopa, 250 mg twice daily, and amlodipine, 10 mg daily.

On physical examination, she is a healthy appearing woman in her second trimester of pregnancy. Her blood pressure is 144/98 mm Hg, and pulse rate is 72 beats/min.

Laboratory test results:

  • Sodium = 140 mEq/L (136-142 mEq/L) (SI: 140 mmol/L [136-142 mmol/L])
  • Potassium = 3.2 mEq/L (3.5-5.0 mEq/L) (SI: 3.2 mmol/L [3.5-5.0 mmol/L])
  • Creatinine = 0.7 mg/dL (0.6-1.1 mg/dL) (SI: 61.9 µmol/L [53.0-97.2 µmol/L])
  • Plasma aldosterone = 35 ng/dL (1-21 ng/dL) (SI: 970.9 pmol/L [27.7-582.5 pmol/L])
  • Plasma renin activity = <0.6 ng/mL per h (0.6-4.3 ng/mL per h)

Measurement of urinary protein is normal. Abdominal MRI without gadolinium administration shows a 1.4-cm left adrenal mass and a normal-appearing right adrenal gland.

In addition to adjusting her medications, which of the following is the best next step in this patient’s evaluation and management?

A. Saline infusion test

B. Adrenal venous sampling

C. Iodocholesterol scintigraphy

D. No additional testing needed; start spironolactone

E. No additional testing needed; perform laparoscopic left adrenalectomy

Question 49

A 74-year-old man is referred for management of hypoglycemia after hyperinsulinemic hypoglycemia is documented. The following laboratory test results were obtained from samples drawn while the patient was experiencing mild cognitive dysfunction:

  • Glucose = 39 mg/dL (70-99 mg/dL) (SI: 2.2 mmol/L [3.9-5.5 mmol/L])
  • C-peptide = 3.3 ng/mL (0.9-4.3 ng/mL) (SI: 1.09 nmol/L [0.30-1.42 nmol/L])
  • Insulin = 10 µIU/mL (1.4-14.0 µIU/mL) (SI: 69.5 pmol/L [9.7-97.2 pmol/L])
  • Sulfonylurea screen (including repaglinide and glimepiride), negative

He has no notable medical history and has had no abdominal operations. When you see him, he has a normal chemistry panel (including serum calcium) and a normal complete blood cell count. Findings from triphasic CT of the abdomen and transabdominal ultrasonography are normal. You then order a selective arterial calcium stimulation test to regionalize the presumed insulinoma. The following results are obtained:

 

Insulin, µIU/mL

Time

Gastroduodenal Arterya

Superior Mesenteric Arterya

Splenic Arterya

Baseline

8.1

9.8

10.1

20 s

10.5

15.7

16.5

40 s

28.5

30.7

14.3

60 s

37.0

45.4

15.0

a Insulin values are measured in blood sampled from the hepatic vein after intra-arterial injection of calcium into the respective arteries/arterial territories supplying the pancreas.

Which of the following should be your next step?

A. Postpone further evaluation until multiple endocrine neoplasia type 1 has been excluded

B. Perform endoscopic ultrasonography and ask the operator to focus on the uncinate process

C. Exclude adrenal insufficiency as the cause of hypoglycemia

D. Ask a surgeon to explore the pancreas with a view to extended distal pancreatectomy

E. Confirm with the radiologist that because of aberrant pancreatic arterial anatomy, you cannot interpret the selective calcium arterial stimulation test results

Question 50

A 27-year-old man has been referred to you for a second opinion regarding endogenous Cushing syndrome. He has a 1-year history of hypertension and has gained 43 lb (19.5 kg) in the past 6 months. He also has facial fullness; muscle weakness; insomnia; and wide, violaceous striae. He is very cushingoid and has a blood pressure of 156/94 mm Hg despite treatment with lisinopril, hydrochlorothiazide, and amlodipine.

Laboratory test results (ordered by another endocrinologist):

  • Sodium = 138 mEq/L (136-142 mEq/L) (SI: 138 mmol/L [136-142 mmol/L])
  • Potassium = 2.9 mEq/L (3.5-5.0 mEq/L) (SI: 2.9 mmol/L [3.5-5.0 mmol/L])
  • Chloride = 98 mEq/L (96-106 mEq/L) (SI: 98 mmol/L [96-106 mmol/L])
  • Serum urea nitrogen = 24 mg/dL (8-23 mg/dL) (SI: 8.6 mmol/L [2.9-8.2 mmol/L])
  • Creatinine = 1.1 mg/dL (0.7-1.3 mg/dL) (SI: 97.2 µmol/L [61.9-114.9 µmol/L])
  • Bicarbonate = 30 mEq/L (21-28 mEq/L) (SI: 30 mmol/L [21-28 mmol/L])
  • Plasma ACTH = 102 pg/mL (10-60 pg/mL) (SI: 22.4 pmol/L [2.2-13.2 pmol/L])
  • Urinary free cortisol = 1944 µg/24 h (4-50 µg/24 h) (SI: 5365 nmol/d [11-138 nmol/d])
  • Late-night salivary cortisol = 2.4 µg/dL (<0.13 µg/dL) (SI: 66 nmol/L [<3.6 nmol/L])
  • Serum cortisol after overnight 1-mg dexamethasone suppression test = 21.4 µg/dL (SI: 590 nmol/L)

MRI of the pituitary is normal. CT of the chest and abdomen shows a 1.5-cm calcified lesion in the right upper lung lobe and bilateral adrenal enlargement without nodules. A right upper lobectomy has been recommended.

Which of the following should you recommend?

A. Bilateral inferior petrosal sinus sampling for ACTH

B. High-dose dexamethasone suppression test

C. Octreotide acetate scintigraphy

D. DDAVP stimulation test

E. Proceeding with the recommended thoracic surgery

Question 51

A 37-year-old woman with a 20-year history of type 1 diabetes mellitus returns to clinic for a routine appointment. Because of weight gain and modest deterioration in glycemic control, the patient has recently joined a gym and she requests guidance in safely increasing her physical activity. She has not required hospitalization subsequent to her diabetes diagnosis. She has had no problems with chest pain or dyspnea during her usual activities, which include walking around her neighborhood. Her diabetes is managed with an insulin pump, and although she has several episodes of hypoglycemia per week, her ability to sense hypoglycemia is preserved and no hypoglycemic episodes have been severe. Her diabetes is complicated by microalbuminuria, peripheral neuropathy without history of ulceration, and closely monitored nonproliferative retinopathy that has not required ophthalmologic intervention. She has no history of orthostatic hypotension or gastroparesis. She has no history of hypertension, dyslipidemia, or cigarette smoking and no family history of premature coronary disease.

On physical examination, she is normotensive and her heart rate is regular. Findings on funduscopic examination are unchanged from those documented at her last visit to your clinic. She has impaired ability to sense a monofilament in a few locations on both feet, but has no foot lesions, foot deformity, or evidence of impaired peripheral circulation. Her examination findings are otherwise unremarkable.

Laboratory test results:

  • Hemoglobin A1c = 8.2% (4.0%-5.6%) (66 mmol/mol [20-38 mmol/mol])
  • Creatinine = 0.7 mg/dL (0.6-1.1 mg/dL) (61.9 ?mol/L [53.0-97.2 ?mol/L])
  • Glomerular filtration rate (estimated) = 94 mL/min per 1.73 m2 (>60 mL/min per 1.73 m2)
  • Urine albumin-to-creatinine ratio = 52 mg/g creat (<30 mg/g)
As the best management plan regarding physical activity, you recommend that the patient do which of the following next?
 

A. Begin a regimen of resistance exercises and aerobic activity

B. Perform only non–weight-bearing exercises

C. Avoid resistance exercises

D. Undergo a graded exercise stress test

E. Begin use of a continuous glucose-monitoring device

Question 52

A 66-year-old woman presents with hirsutism. She had regular menses until she went through menopause at age 51 years. Four years ago, she began developing hirsutism on her back, chest, upper abdomen, and face, along with frontal, male-pattern balding. She also notes increased libido. Her medical history is unremarkable.

On physical examination, her blood pressure is 130/80 mm Hg. You note frontal and occipital balding and dark hair between the breasts and on the face, upper back, upper and lower abdomen, upper arms, and thighs. She has no dorsal cervical or supraclavicular fat pad. She has clitoromegaly and no palpable ovarian masses. Her height is 64.5 in (163.8 cm), and weight is 149 lb (67.7 kg) (BMI = 25.2 kg/m2).

Laboratory test results:

  • Total testosterone = 160 ng/dL (8-60 ng/dL) (SI: 5.6 nmol/L [0.3-2.1 nmol/L])
  • DHEA-S = 45 µg/dL (15-157 µg/dL) (SI: 1.2 µmol/L [0.41-4.25 µmol/L])
  • LH = 25 mIU/mL (>30 mIU/mL) (SI: 25 IU/L [>30 IU/L])
  • FSH = 10.7 mIU/mL (>30 mIU/mL) (SI: 10.7 IU/L [>30 IU/L])
  • Estradiol = <20 pg/mL (<20 pg/mL) (SI: 73.4 pmol/L [<73.4 pmol/L])
Which of the following tests would be most useful now?

A. Adrenal CT

B. Free testosterone measurement

C. Ovarian ultrasonography

D. Oral glucose tolerance test

E. GnRH agonist test

Question 53

A 21-year-old man with osteogenesis imperfecta is transferring his care from pediatric endocrinology to your adult endocrinology practice. He is wheelchair bound. Osteogenesis imperfecta was diagnosed at birth when a femur fracture was noted shortly after delivery. He has had multiple fractures of all extremities including bilateral femur fractures and bilateral tibial fractures. He recently developed pseudoarthrosis of his bilateral humeri. He has been treated with weekly alendronate. Because of worsening dysphagia and abdominal pain, which limits his adherence to this medication, he would like his regimen to be transitioned to an intravenous bisphosphonate. There is no family history of osteogenesis imperfecta or other metabolic bone disorders.

On physical examination, he is markedly short, has severe scoliosis, and has shortened and bowed deformities of the upper and lower extremities. Sclerae are slightly tinted blue. His blood pressure is 128/76 mm Hg, and pulse rate is 94 beats/min. His height is 39 in (99.1 cm), and weight is 50 lb (22.7 kg) (BMI = 23.1 kg/m2).

In addition to musculoskeletal complications, this patient is at highest risk for which of the following?

A. Aortic root dilation

B. Premature atherosclerotic cardiovascular disease

C. Bone cancers

D. Retinal detachment

E. Premature cataracts

Question 54

You are called to the emergency department to advise on the management of a 25-year-old man who has been admitted to the hospital after he collapsed and had a seizure while running a marathon earlier in the day. He has no notable medical history and takes no prescribed medications. His seizure terminated after administration of intravenous lorazepam.

On physical examination, he is confused and disoriented. His blood pressure is 98/65 mm Hg, and resting pulse rate is 100 beats/min. He has dry mucous membranes although skin turgor is normal. No overt focal neurologic signs are elicited.

Laboratory test results:

  • Sodium = 112 mEq/L (136-142 mEq/L) (SI: 112 mmol/L [136-142 mmol/L])
  • Potassium = 3.9 mEq/L (3.5-5.0 mEq/L) (SI: 3.9 mmol/L [3.5-5.0 mmol/L])
  • Serum urea nitrogen = 14 mg/dL (8-23 mg/dL) (SI: 5.0 mmol/L [2.9-8.2 mmol/L])
  • Creatinine = 1.2 mg/dL (0.7-1.3 mg/dL) (SI: 106.1 ?mol/L [61.9-114.9 ?mol/L])
Which of the following is the most appropriate treatment of this patient’s hyponatremia?

A. 1.8% saline: 500 mL over 20 minutes

B. 3.0% saline: 100 mL over 20 minutes

C. 0.9% saline: 500 mL stat

D. Intravenous conivaptan

E. Oral urea treatment

Question 55

A 52-year-old woman comes to your office concerned about osteoporosis as a consequence of bariatric surgery. Her mother, who is 76 years old, just experienced a painful vertebral compression fracture. The patient is worried about her own fracture risk since she is considering undergoing bariatric surgery to manage her obesity. She has never had a fracture. She has taken calcium and vitamin D supplements since menopause 2 years ago. She stays physically active, walking 30 to 45 minutes 3 to 4 times per week. She underwent DXA 1 month ago, which revealed T scores of –1.1 and –1.4 at the spine and femoral neck, respectively. Current medications include a multivitamin; calcium citrate, 1200 mg daily; and vitamin D, 2000 IU daily.

On physical examination, her height is 66 in (167.6 cm) and weight is 248 lb (112.7 kg) (BMI = 40 kg/m2). Her blood pressure is 125/85 mm Hg, and pulse rate is 75 beats/min. The rest of her examination findings are normal.

Laboratory test results:

  • Chemistry panel (including calcium and alkaline phosphatase), normal
  • 25-Hydroxyvitamin D = 39 ng/mL (25-80 ng/mL [optimal]) (SI: 97.3 nmol/L [62.4-199.7 nmol/L])
  • PTH = 50 pg/mL (10-65 pg/mL) (SI: 50 ng/L [10-65 ng/L])
  • Urinary calcium = 188 mg/g creatinine
Which of the following changes is most likely to be observed in this patient if she is evaluated 12 months after undergoing a Roux-en-Y gastric bypass operation?

A. Decreased bone resorption markers

B. Decreased femoral neck bone mineral density

C. Increased incidence of hip fracture

D. Decreased PTH levels

E. Increased urinary calcium excretion

Question 56

A 23-year-old man whom you have been treating for classic congenital adrenal hyperplasia returns to clinic after a prolonged absence. Shortly after birth, newborn screening led to the diagnosis of salt-losing congenital adrenal hyperplasia due to 21-hydroxylase deficiency. He was appropriately treated through infancy and childhood with hydrocortisone 3 times daily and fludrocortisone twice daily. Pubertal development was normal, and he has remained well. His current therapy consists of dexamethasone, 0.25 mg daily, and fludrocortisone, 0.1 mg daily. He now presents to reestablish care. He describes an enlarged and painful testis.

On physical examination, his height is 69 in (175.3 cm), and weight is 205 lb (93.2 kg) (BMI = 30.3 kg/m2). His blood pressure is 127/64 mm Hg, and pulse rate is 78 beats/min. His skin is darker than you would expect for the season, and he has brown palmar creases. His right testis is normal on examination, but the left testis is enlarged and tender.

Laboratory test results:

  • 17-Hydroxyprogesterone = 2600 ng/dL (<220 ng/dL) (SI: 78.8 nmol/L [<6.67 nmol/L])
  • DHEA-S = 500 ?g/dL (89-457 ?g/dL) (SI: 13.6 ?mol/L [2.41-12.38 ?mol/L])
  • Testosterone = 806 ng/dL (300-900 ng/dL) (SI: 27.9 nmol/L [10.4-31.2 nmol/L])
  • ACTH = 745 pg/mL (10-60 pg/mL) (SI: 163.9 pmol/L [2.2-13.2 pmol/L])
  • Basic metabolic panel, normal
In addition to ordering ultrasonography and counseling him on the importance of medication adherence, which of the following is the best next step?

A. Refer for testicular resection

B. Refer for testicular radiation

C. Increase dexamethasone to 0.75 mg daily at bedtime

D. Change dexamethasone to hydrocortisone, 20 mg daily in divided doses

E. Add mitotane

Question 57

A 30-year-old woman presents for preconception planning. She has had type 1 diabetes mellitus since age 13 years and she also has hypertension. Her recent hemoglobin A1c values have ranged from 6.7% to 7.8% (50-62 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol]). She currently has 2 to 3 episodes of hypoglycemia per week. She had an uncomplicated pregnancy at age 25 years, and the baby was born full term and healthy. Mild background retinopathy was documented on a dilated eye examination 8 months ago.

The patient administers 17 units of insulin glargine at bedtime. She uses carbohydrate counting to estimate the premeal dose of insulin lispro. She takes lisinopril, 10 mg daily, and labetalol, 100 mg twice daily. She does not smoke cigarettes, and she has 1 to 2 alcoholic beverages per week. She exercises regularly.

On physical examination, her height is 68 in (172.7 cm) and weight is 138 lb (62.7 kg) (BMI = 21 kg/m2). Her blood pressure is 138/85 mm Hg, and pulse rate is 70 beats/min. Funduscopic examination reveals no microaneurysms on nondilated eye exam. The rest of the examination findings are normal.

Laboratory test results:

  • Hemoglobin A1c = 6.6% (4.0%-5.6%) (49 mmol/mol [20-38 mmol/mol])
  • Urine albumin-to-creatinine ratio = 42 mg/g creat (<30 mg/g creat)
Which of the following do you recommend before the patient becomes pregnant?

A. Intensify insulin therapy

B. Initiate insulin pump therapy

C. Perform a dilated eye examination

D. Substitute nifedipine for lisinopril

E. Substitute nifedipine for labetalol

Question 58

A 42-year-old male-to-female transsexual patient is referred to you with concerns regarding her voice. Gender dysphoria was diagnosed 3 years ago after a thorough evaluation by a mental health professional. The patient was subsequently referred to an endocrinologist who started treatment with spironolactone to block androgen action and estrogen therapy to induce feminization. Within 12 to 18 months of hormone therapy, there was satisfactory breast development, softening of the skin, decrease in terminal hair growth, and redistribution of body fat.

Although the patient is satisfied with her feminine appearance, she is concerned that her voice remains unchanged despite 3 years of hormone therapy. It is still low-pitched and masculine, often resulting in gender misattributions over the phone, and is an impediment to socializing and a source of embarrassment. She discussed this issue with her local endocrinologist who has referred her to you for further evaluation. She is currently on spironolactone, 200 mg daily, and a transdermal estradiol patch, 200 mcg twice weekly, and she reports no adverse effects. The patient does not have any other notable medical history.

During your intake interview, you note that she does have a masculine voice. On physical examination, her blood pressure is 132/68 mm Hg and pulse rate is 76 beats/min. Her height is 68 in (172.7 cm), and weight is 177 lb (80.5 kg) (BMI = 26.9 kg/m2). There are no terminal hairs on the face, chest, or extremities. Her breast development is normal. The rest of her examination findings are unremarkable.

Laboratory test results:

  • Testosterone = 37 ng/dL (SI: 1.3 nmol/L)
  • Estradiol = 172 pg/mL (SI: 631.4 pmol/L)
  • LH = 0.3 mIU/mL (SI: 0.3 IU/L)
  • FSH = 0.5 mIU/mL (SI: 0.5 IU/L)
  • Potassium = 3.9 mEq/L (3.5-5.0 mEq/L) (SI: 3.9 mmol/L [3.5-5.0 mmol/mol])
Which of the following is the best next management step?

A. Substitute transdermal estradiol patch with oral ethinyl estradiol, 100 mcg daily

B. Substitute spironolactone with finasteride, 5 mg daily

C. Refer for speech therapy

D. Substitute spironolactone with depo injections of a GnRH agonist

E. Refer for pitch-raising surgery

Question 59

A 28-year-old woman with Graves disease in the 18th week of pregnancy and on methimazole is referred for medication adjustment.

Which of the following sets of laboratory results is within recommended targets for this patient?
 

TSH

Free T4

Total T3

A.

0.05 mIU/L

2.1 ng/dL
(27.0 pmol/L)

400 ng/dL
(6.2 nmol/L)

B.

0.1 mIU/L

1.8 ng/dL
(23.2 pmol/L)

350 ng/dL
(5.4 nmol/L)

C.

1.5 mIU/L

1.5 ng/dL
(19.3 pmol/L)

330 ng/dL
(5.1 nmol/L)

D.

2.5 mIU/L

1.3 ng/dL
(16.7 pmol/L)

280 ng/dL
(4.3 nmol/L)

E.

3.5 mIU/L

1.0 ng/dL
(12.9 pmol/L)

210 ng/dL
(3.2 nmol/L)

Reference ranges: TSH, 0.5-5.0 mIU/L; free T4, 0.8-1.8 ng/dL (SI: 10.30-23.17 pmol/L); total T3, 70-200 ng/dL (SI: 1.08-3.08 nmol/L).

A. A

B. B

C. C

D. D

E. E

Question 60

A 67-year-old woman is found to have hyperthyroidism with a small goiter.

Thyroid function results:

  • Free T4 concentration = 2.8 ng/dL (0.8-1.8 ng/dL) (SI: 30.0 pmol/L [10.30-23.17 pmol/L])
  • TSH = 5.9 mIU/L (0.5-5.0 mIU/L)

A TSH-secreting pituitary adenoma is suspected, and MRI shows a 2.4-cm tumor with cavernous sinus invasion. After transsphenoidal surgery, the patient’s free T4 level remains elevated at 1.8 ng/dL (23.2 pmol/L), and her TSH concentration is 2.7 mIU/L. MRI shows persistent tumor in the cavernous sinus.

Which of the following medical treatments would be expected to give the best overall results in this case?

A. Cabergoline

B. Methimazole

C. Radioactive iodine

D. Lanreotide depot

E. Temozolomide

Question 61

A 20-year-old woman recently underwent total thyroidectomy for papillary thyroid cancer. Her surgical pathology revealed multiple foci of thyroid cancer within the right lobe. The largest focus was 1.1 cm; the other 3 foci were 0.1 to 0.2 cm. Surgical resection margins were negative, no extrathyroidal extension or vascular invasion was identified, and no suspicious lymph nodes were found or removed at the time of her operation. The patient has no family history of thyroid cancer.

She was prescribed levothyroxine and referred to you by her surgeon, who had explained that she would be treated with radioactive iodine (131I).

Which of the following summarizes what you should discuss with her regarding radioiodine remnant ablation?
 

Effect on Thyroid Cancer Recurrence

Effect on Risk of Death From Thyroid Cancer

Recommended 131I Administered Activity

A.

Decreased

Decreased

30 mCi

B.

Decreased

Decreased

100 mCi

C.

Decreased

No change

30 mCi

D.

Decreased

No change

100 mCi

E.

No change

No change

None


A. A

B. B

C. C

D. D

E. E

Question 62

A 42-year-old Hispanic woman has questions regarding her risk of developing diabetes. She is overweight (BMI = 28 kg/m2), and her weight has been stable for 10 years since the delivery of her third child. She had a history of gestational diabetes treated with diet and exercise during her last pregnancy. There is a family history of diabetes in approximately one-half of her family members, and none of them were diagnosed in childhood. She has mild hypertension treated with a calcium channel blocker.

Laboratory test results:

  • Fasting glucose = 112 mg/dL (70-99 mg/dL) (SI: 6.2 mmol/L [3.9-5.5 mmol/L])
  • Glucose 2 hours after 75-g oral glucose load = 174 mg/dL (<140 mg/dL) (SI: 9.7 mmol/L [<7.8 mmol/L])
  • LDL cholesterol = 153 mg/dL (<100 mg/dL [optimal] (SI: 3.96 mmol/L [<2.59 mmol/L])
  • HDL cholesterol = 38 mg/dL (>60 mg/dL [optimal]) (SI: 0.98 mmol/L [>1.55 mmol/L])
  • Triglycerides = 153 mg/dL (<150 mg/dL [optimal]) (SI: 1.73 mmol/L [<3.88 mmol/L])
Which of the following components of her presentation contributes most strongly to her personal risk of diabetes?

A. Family history of type 2 diabetes

B. Presence of metabolic syndrome

C. Personal history of gestational diabetes

D. Current glucose values

E. Hispanic ethnicity

Question 63

A 28-year-old woman presents with premenstrual mood changes that are disrupting her life. Menarche was at age 12 years, and her cycles are regular. She has always had painful periods and has tried over-the-counter medications and nonsteroidal anti-inflammatory agents with modest success. Her mood is worse in the week before her period and during her period. She has no family history of clotting disorders. She is not interested in fertility at this time. She wonders what she can do.

Which of the following is the best recommendation?

A. Tricyclic antidepressant and daily multivitamin

B. Serotonin reuptake inhibitor and a low-dosage oral contraceptive pill

C. Serotonin reuptake inhibitor and vitamin B6 supplementation

D. Serotonin reuptake inhibitor and placement of a levonorgestrel-releasing intrauterine device

E. Vitamin B6 supplementation and a low-dosage oral contraceptive pill

Question 64

A 32-year-old man presents with hip pain and the radiographic findings shown (see image).

Laboratory test results:

  • Serum calcium = 8.2 mg/dL (8.2-10.2 mg/dL) (SI: 2.1 mmol/L [2.1-2.6 mmol/L])
  • Phosphorus = 2.2 mg/dL (2.3-4.7 mg/dL) (SI: 0.7 mmol/L [0.7-1.5 mmol/L])
  • Creatinine = 0.9 mg/dL (0.7-1.3 mg/dL) (SI: 79.6 µmol/L [61.9-114.9 µmol/L])
  • Serum alkaline phosphatase = 346 U/L (50-120 U/L) (SI: 5.78 µkat/L [0.84-2.00 µkat/L])
Measurement of which of the following is most likely to provide this patient’s diagnosis?

A. Fibroblast growth factor 23

B. 1,25-Dihydroxyvitamin D

C. 25-Hydroxyvitamin D

D. PTH

E. C-telopeptide

Question 65

A 52-year-old man comes for evaluation to determine whether his progressive fatigue for the past 18 months relates to a low testosterone level. He also has morning headaches and daytime somnolence. He recently saw his primary care physician who documented his total testosterone level to be 282 ng/dL (9.8 nmol/L). The patient has a diminished libido. He has hypertension that is treated with a diuretic. He is married with 2 children.

On physical examination, he is obese but not cushingoid (BMI = 36.2 kg/m2). His visual fields are normal. Acanthosis nigricans is present in the axillae. His testes are 25 mL bilaterally. Muscle strength is normal.

Laboratory test results:

  • Total testosterone (8 AM) = 296 ng/dL (300-900 ng/dL) (SI: 10.3 nmol/L [10.4-31.2 nmol/L]) (measured by mass spectrometry)
  • Fasting glucose = 112 mg/dL (70-99 mg/dL) (SI: 6.2 mmol/L [3.9-5.5 mmol/L])
  • Albumin = 4.5 g/dL (3.5-5.0 g/dL) (SI: 45 g/L [35-50 g/L])
  • Serum cortisol (8 AM) = 16.2 µg/dL (5-25 µg/dL) (SI: 446.9 nmol/L [137.9-689.7 nmol/L])
  • Hematocrit = 41.3% (41%-50%) (SI: 0.413 [0.41-0.51])
Measuring which of the following should be the next diagnostic step in this patient’s evaluation?

A. Iron saturation

B. Gonadotropins

C. Prolactin

D. Free testosterone

E. 24-Hour urinary free cortisol

Question 66

A 56-year-old man is referred for evaluation of a neck mass. The patient notes dysphagia with solid foods and positional dyspnea when lying on his right side. His medical history is noncontributory.

On physical examination, he has a large goiter extending below the clavicle on the left side. His serum TSH concentration is 0.2 mIU/L, and radioiodine uptake is 12% at 24 hours. The scan is difficult to interpret because the mass is mostly substernal, with attenuation of the image.

CT of the neck is shown (see image).

Which of the following is the best next step in this patient’s management?

A. Levothyroxine suppressive therapy

B. Radioiodine therapy using recombinant human TSH

C. Thermal ablation therapy

D. Thyroidectomy from collar incision

E. No intervention until symptoms progress

Question 67

A 27-year-old man is referred to you for evaluation of hypocalcemia. He has a long history of bone pain and has only recently sought medical attention because his symptoms have worsened. Recent laboratory testing revealed low calcium and elevated PTH values. He has no fracture history and has never had a kidney stone. He is a high school graduate and reports his academic achievement was average. Additional medical problems include hypothyroidism and hypogonadism (also recently diagnosed); he takes appropriate replacement therapy and is adherent to this regimen. His local physician told him that his condition may run in families. The patient and his wife have a 7-year-old son, so the patient has questions regarding inheritance. The patient is adopted and his family history is unavailable.

On physical examination, he is a short, obese man with a round face and shortened fourth and fifth metacarpals bilaterally. His blood pressure is 139/86 mm Hg, and pulse rate is 77 beats/min. His height is 60 in (152.4 cm), and weight is 216 lb (98.2 kg) BMI = 42.2 kg/m2).

Laboratory test results:

  • Total calcium = 7.7 mg/dL (8.2-10.2 mg/dL) (SI: 1.9 mmol/L [2.1-2.6 mmol/L])
  • 25-Hydroxyvitamin D = 20 ng/mL (25-80 ng/mL [optimal] (SI: 49.9 nmol/L [62.4-199.7 nmol/L])
  • 1,25-Dihydroxyvitamin D = 45 pg/mL (16-65 pg/mL) (SI: 117 pmol/L [41.6-169.0 pmol/L])
  • Phosphorus = 6.5 mg/dL (2.3-4.7 mg/dL) (SI: 2.1 mmol/L [0.7-1.5 mmol/L])
  • PTH = 475 pg/mL (10-65 pg/mL) (SI: 475 ng/L [10-65 ng/L])
  • Creatinine = 2.3 mg/dL (0.7-1.3 mg/dL) (SI: 203.3 µmol/L [61.9-114.9 µmol/L])
  • Albumin = 4.2 g/dL (3.5-5.0 g/dL) (SI: 42 g/L [35-50 g/L])
  • TSH = 1.8 mIU/L (0.5-5.0 mIU/L)
  • Free testosterone = 23 ng/dL (9.0-30 ng/dL) (SI: 0.80 nmol/L [0.31-1.04 nmol/L])
How should you counsel him regarding the likely inheritance of this disorder?

A. He most likely inherited a gene mutation from his father; his son has a 50% chance of inheriting the mutation and being affected

B. He most likely inherited a gene mutation from his mother; his son has a 50% chance of inheriting the mutation but likely will not have endocrine abnormalities

C. He most likely inherited 2 gene mutations (1 from his mother and 1 from his father); his son will be affected

D. The disorder results from a postzygotic gene mutation; his son has the same risk as the general population

E. This disorder is idiopathic and has no clear genetic basis; his son has the same risk as the general population

Question 68

A 33-year-old man has been referred to you for evaluation of Cushing syndrome. He has had a 20-lb (9.1-kg) weight gain in the past 9 months accompanied by the onset of hypertension and edema. He has noted marked weakness, especially when climbing stairs. His family history is negative for any endocrine disorders. He takes no medications.

On physical examination, he has facial rounding and supraclavicular and dorsocervical fat accumulation. His blood pressure is 168/110 mm Hg, and pulse rate is 94 beats/min. His height is 75 in (190.5 cm), and weight is 220 lb (100 kg) (BMI = 27.5 kg/m2). He has wide, violaceous striae on his abdomen; proximal muscle weakness; and 2+ pretibial edema.

Laboratory test results:

  • Sodium = 142 mEq/L (136-142 mEq/L) (SI: 142 mmol/L [136-142 mmol/L])
  • Potassium = 3.0 mEq/L (3.5-5.0 mEq/L) (SI: 3.0 mmol/L [3.5-5.0 mmol/L])
  • Creatinine = 1.1 mg/dL (0.7-1.3 mg/dL) (SI: 97.2 ?mol/L [61.9-114.9 ?mol/L])
  • Urinary free cortisol = 632 ?g/24 h (4-50 ?g/24 h) (SI: 1744 nmol/d [11-138 nmol/d])
  • Late-night salivary cortisol = 2.1 ?g/dL (<0.13 ?g/dL) (SI: 58 nmol/L [<3.6 nmol/L])
  • DHEA-S = 678 ?g/dL (65-334 ?g/dL) (SI: 18.4 ?mol/L [1.76-9.05 ?mol/L])
  • Basal plasma ACTH = <5 pg/mL (10-60 pg/mL) (SI: <1.1 pmol/L [2.2-13.2 pmol/L])
Which of the following imaging studies and accompanying descriptions are most likely in this man

A. Hounsfield units &lt;10 in each nodule

B. Increased T1-weighted signal in the pituitary gland

C. Unenhanced Hounsfield units = 32 with relative enhancement washout of 58%

D. Enhanced Hounsfield units = 78 with relative enhancement washout of 12%

E. Unenhanced Hounsfield units = 52 with absolute enhancement washout of 74%

Question 69

A 36-year-old woman with a peak lifetime BMI of 46 kg/m2 had a laparoscopic gastric bypass operation in another state 8 weeks ago. She initially did well, but over the last 3 weeks she began to experience episodes of vomiting. Over the last 5 days, she has been vomiting almost everything she eats. Over the last 2 days, her husband says that she has become increasingly confused, dysarthric, and unsteady on her feet. On neurologic examination, she is clearly confused, has nystagmus, is unsteady on standing, has decreased sensation on her lower extremities, and has a right third nerve palsy.

This patient most likely has a deficiency of which of the following?

A. Vitamin B12

B. Vitamin D (severe)

C. Thiamine

D. Folate

E. Zinc

Question 70

A 27-year-old woman with a history of hypothyroidism after thyroidectomy has been trying to become pregnant and is now 1 week late for her menses. A home pregnancy kit had a positive result. Thyroid function tests 1 month ago documented a serum TSH value of 1.2 mIU/L (0.5-5.0 mIU/L). Her primary care physician requests your management advice.

Which of the following recommendations is consistent with current American Thyroid Association guidelines applicable to this circumstance?

A. Decrease the levothyroxine dosage to achieve a target TSH concentration of 2.5 mIU/L

B. Continue the current levothyroxine dosage

C. Increase the levothyroxine dosage by 30%

D. Increase the levothyroxine dosage by 50%

E. Initiate liothyronine, 5 mcg twice daily, and continue the current levothyroxine dosage

Question 71

A 34-year-old woman with a 15-year history of type 1 diabetes mellitus remains hospitalized after a cholecystectomy and intravenous insulin infusion is being used for glycemic control. She has had continued need for narcotics to address postoperative shoulder pain. Yesterday she tolerated a clear-liquid diet, and she ate less than 50% of the solid food on the meal tray that she received this morning. She is expected to be discharged from the hospital within the next 1 to 2 days. At home, she manages her diabetes with an insulin pump. Her admission hemoglobin A1c value is 6.9% (52 mmol/mol). Her total insulin requirements when using the pump are approximately 23 units per day, with her basal insulin comprising 10.7 units per day.

Her bolus insulin calculator settings include:

  • Insulin-to-carbohydrate ratio: 1:14 g of carbohydrate
  • Sensitivity ratio: 1:86
  • Target glucose: 110 mg/dL (6.1 mmol/L)

Her intravenous insulin infusion at 0.5 to 0.6 units/h has maintained her overnight blood glucose between 110 and 160 mg/dL (6.1-8.9 mmol/L).

On physical examination, the patient is somnolent but arousable, and she is briefly disoriented after awakening. She has only mild tenderness on palpation of the abdomen, but the rest of her physical examination findings are normal.

Which of the following is the best next step in this patient’s care?
 

A. Continue intravenous insulin infusion until the patient is consistently eating more than 50% of each meal

B. Transition to 10 units basal insulin analogue once daily and a supplemental scale of rapid-acting analogue insulin given at mealtime if premeal blood glucose is greater than 110 mg/dL (&gt;6.1 mmol/L)

C. Transition to 10 units basal insulin analogue once daily and rapid-acting analogue insulin given immediately after meals (2 units if &lt;50% of meal eaten; 4 units if &gt;50% of meal eaten)

D Transition to insulin pump therapy at her usual basal rate and bolus calculator settings

E. Transition to insulin pump therapy, but decrease all basal rates by 20% and reduce the carbohydrate factor to 1 unit per 16 g of carbohydrates eaten at meals

Question 72

A 22-year-old man is brought to your office by his parents, who are convinced that he has Cushing syndrome. Over the past 2 years, they have watched him become increasingly withdrawn and have witnessed the evolution of disturbing physical changes, including 45-lb (20.5-kg) weight gain despite dieting and exercise. During the last several months, he has developed hypertension. They have taken their son to many physicians for evaluation, all of whom have said that there is no hormonal abnormality.

On physical examination, his blood pressure is 140/92 mm Hg and he has a small dorsocervical fat pad, acne, and a ruddy complexion.

Laboratory test results:

  • ACTH = 40 pg/mL (10-60 pg/mL) (SI: 8.8 pmol/L [2.2-13.2 pmol/L])
  • Serum cortisol (8 AM) = 18 ?g/dL (5-25 ?g/dL) (SI: 496.6 nmol/L [137.9-689.7 nmol/L])
  • Urinary cortisol = 60 ?g/24 h (4-50 ?g/24 h) (SI: 165.6 nmol/d [11-138 nmol/d])
Which of the following should be performed next?

A. Bilateral adrenal vein sampling

B. Inferior petrosal sinus sampling

C. High-dose dexamethasone suppression test

D. Salivary cortisol measured at midnight on 3 consecutive nights

E. Pituitary MRI

Question 73

A 32-year-old woman is seen for follow-up of a weight-loss effort. Since her diagnosis of type 2 diabetes mellitus 1 year ago, she has been focusing on implementing a more healthful lifestyle. She stopped smoking, but she gained weight. She has been participating in a meal replacement program for the past 6 months, which includes twice-weekly group meetings. She uses an activity tracking device and tries to achieve 5000 to 10,000 steps daily. Although she has lost some weight, she is hoping to lose more. She asks about medications for weight loss.

Her medical history is notable for type 2 diabetes mellitus controlled with metformin monotherapy, polycystic ovary syndrome, recurrent urinary tract infections, depression, and hypothyroidism. Current medications are metformin, 850 mg twice daily; sertraline, 50 mg daily; levothyroxine, 112 mcg daily; and an oral contraceptive.

Findings on physical examination are normal. Her hemoglobin A1c level is 6.8% (51 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol]). Her TSH concentration is 4.2 mIU/L (reference range, 0.5-5.0 mIU/L).

One year ago (before she began lifestyle changes), her weight was 230 lb (104.5 kg) and height was 66.5 in (168.9 cm) (BMI = 36.6 kg/m2). Her current weight is 219 lb (99.5 kg) (BMI = 34.8 kg/m2).

In addition to recommending ongoing diet and exercise, which of the following medication changes would provide the most benefit in managing her type 2 diabetes mellitus and obesity?

A. Add dapagliflozin

B. Add liraglutide

C. Increase the levothyroxine dosage

D. Increase the metformin dosage

E. Discontinue the oral contraceptive

Question 74

A 67-year-old man with end-stage kidney disease due to hypertension has been receiving hemodialysis for 8 years. He comes to you because of multiple vertebral fractures, a pelvic fracture, and a femoral neck T score of ?3.9. Current medications include calcitriol, 0.5 mcg twice daily, and cinacalcet, 90 mg twice daily.

Laboratory test results:

  • Creatinine = 5.5 mg/dL (0.7-1.3 mg/dL) (SI: 486.2 µmol/L [61.9-114.9 µmol/L])
  • Serum calcium = 7.8 mg/dL (8.2-10.2 mg/dL) (SI: 2.0 mmol/L [2.1-2.6 mmol/L])
  • Albumin = 4.0 g/dL (3.5-5.0 g/dL) (SI: 40 g/L [35-50 g/L])
  • Phosphorus = 5.2 mg/dL (2.3-4.7 mg/dL) (SI: 1.7 mmol/L [0.7-1.5 mmol/L])
  • 25-Hydroxyvitamin D = 24 ng/mL (25-80 ng/mL [optimal]) (SI: 59.9 nmol/L [62.4-199.7 nmol/L])
  • PTH = 78 pg/mL (10-65 pg/mL) (SI: 78 ng/L [10-65 ng/L])
  • Total alkaline phosphatase = 125 U/L (50-120 U/L) (SI: 2.09 µkat/L [0.84-2.00 µkat/L])

An iliac crest biopsy is done after double-tetracycline labeling and results will be available in 4 weeks.

While awaiting bone biopsy results, which of the following changes in management should be made immediately?

A. Increase the calcitriol dosage

B. Decrease the cinacalcet dosage

C. Add alendronate

D. Add denosumab

E. Add zoledronic acid

Question 75

A 52-year-old man is admitted to the hospital for treatment of urosepsis. Antibiotics and intravenous fluids are started. On admission, his laboratory evaluation was normal except for positive urine cultures. Blood cultures are negative. He has an 8-year history of type 2 diabetes mellitus. He has been taking maximum dosages of metformin and glipizide. Canagliflozin was started 3 months ago when his hemoglobin A1c level was 8.7% (77 mmol/mol) (reference range, 4.0%-5.6% [20-38 mmol/mol]). Additional medications include lisinopril, metoprolol, furosemide, and simvastatin. He takes controlled-release oxycodone for chronic back pain and lorazepam for anxiety.

On physical examination, the patient is somnolent but arousable. He can answer questions after prompting and is oriented. His height is 70 in (177.8 cm), and weight is 224 lb (101.8 kg) (BMI = 32.1 kg/m2). His blood pressure is 142/92 mm Hg, pulse rate is 94 beats/min.

During the first 3 days of the hospitalization, metformin, glipizide, and canagliflozin are continued at his home dosages. A carbohydrate-controlled diet is initiated, but he has been eating only about half of the food provided. Since admission, his glucose values have ranged from 98 to 201 mg/dL (5.4-11.2 mmol/L). He has not required any supplemental insulin. On the third hospital day, the patient’s condition deteriorates and he is transferred to a large teaching hospital and additional laboratory tests are ordered.

Arterial blood gases:

  • pH = 7.13 (7.35-7.45)
  • Po2 = 107 mm Hg (80-100 mm Hg) (SI: 14.2 kPa [10.6-13.3 kPa])
  • Pco2 = 17 mm Hg (35-45 mm Hg) (SI: 2.3 kPa [4.7-6.0 kPa])
  • Bicarbonate = 6 mEq/L (21-28 mEq/L) (SI: 6 mmol/L [21-28 mmol/L])
  • Lactic acid = 21.0 mg/dL (5.4-20.7 mg/dL) (SI: 2.3 mmol/L [0.6 to 2.3 mmol/L])
  • Hemoglobin A1c = 7.3% (4.0%-5.6%) (56 mmol/mol [20-38 mmol/mol])
  • Random glucose = 152 mg/dL (8.4 mmol/L)
You discontinue his oral antihyperglycemic agents and start intravenous fluids. Which of the following should be started as the best next step?

A. Intravenous insulin at 0.1 units/kg per h with intravenous glucose

B. Intravenous insulin at 0.1 units/kg per h with sodium bicarbonate infusion

C. Basal insulin, 20 units once daily

D. Basal insulin, 20 units once daily, plus insulin lispro, 5 units with each meal

E. Insulin lispro, 1 unit per 50 mg/dL for glucose values above 150 mg/dL (&gt;8.3 mmol/L)

Question 76

A 44-year-old man with a remote history of Graves disease is referred for evaluation. Three years earlier, he developed ocular pain, chemosis, and eyelid swelling after receiving radioiodine therapy. Currently he has persistent diplopia and inability to fully close his eyes while sleeping. On physical examination, he has pain with eye movement, but no conjunctival erythema or edema and no lid swelling. Proptosis measures 26 mm on the right side and 28 mm on the left side, with dysconjugate gaze (see image). He takes levothyroxine, and his current TSH concentration is 1.2 mIU/L (0.5-5.0 mIU/L).

Which of the following should be recommended for this patient?

A. Orbital radiotherapy

B. Rituximab therapy

C. Pulse corticosteroid therapy

D. Orbital decompression followed by strabismus surgery

E. Strabismus surgery alone

Question 77

A 41-year-old man is referred for management of his lipids. Two years ago, he was found to have markedly elevated triglycerides and therapy with a medication was initiated. This medication reportedly resulted in a good response, but the patient decided to stop taking it. He is otherwise healthy and does not take any medications. He does not smoke cigarettes, but drinks 15 alcoholic beverages every week. He eats fast food on a daily basis. Both of his parents have type 2 diabetes mellitus, and many paternal family members are known to have high triglycerides, but there is no family history of premature atherosclerotic cardiovascular disease. He has a healthy 13-year-old daughter.

On physical examination, his height is 72 in (182.9 cm) and weight is 170 lb (77.3 kg) (BMI = 23.1 kg/m2). His blood pressure is 112/76 mm Hg, and pulse rate is 74 beats/min. He has no rashes, his abdomen is not tender, and there is no hepatosplenomegaly. The rest of his physical examination findings are unremarkable.

Laboratory test results (sample drawn while fasting):

  • Total cholesterol = 456 mg/dL (<200 mg/dL [optimal]) (SI: 11.81 mmol/L [<5.18 mmol/L])
  • HDL cholesterol = 16 mg/dL (>60 mg/dL [optimal]) (SI: 0.41 mmol/L [>1.55 mmol/L])
  • Triglycerides = 3790 mg/dL (<150 mg/dL [optimal]) (SI: 42.83 mmol/L [<3.88 mmol/L])
  • Apolipoprotein B = 98 mg/dL (50-110 mg/dL) (SI: 0.98 g/L [0.5-1.1 g/L])
  • Hemoglobin A1c = 5.6% (4.0%-5.6%) (38 mmol/mol [20-38 mmol/mol])
  • TSH = 2.4 mIU/L (0.5-5.0 mIU/L)
In addition to recommending lifestyle changes, which of the following is the most important treatment to initiate for this patient’s markedly elevated triglycerides?

A. A statin

B. A statin + ezetimibe

C. Niacin

D. A fibrate

E. Fish oil

Question 78

While combing her hair, a 50-year-old woman noticed a swelling in her neck and vague discomfort in the area. She has some difficulty swallowing and has also noted hoarseness in her voice. She has no family history of thyroid disease and no personal history of radiation exposure.

On physical examination, vital signs are normal. A 3-cm nodule involves most of the right lobe of the thyroid gland. It is quite hard, but it moves with swallowing. The left lobe is small and soft. No lymph nodes are palpable.

Laboratory test results:

  • TSH = 2.1 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 1.5 ng/dL (0.8-1.8 ng/dL) (SI: 19.31 pmol/L [10.30-23.17 pmol/L])

Thyroid ultrasonography (see image) demonstrates a noncalcified isoechoic solid nodule in the right thyroid lobe. Fine-needle aspiration biopsy reveals a very cellular aspirate. Little colloid is present, except in a few dense clumps surrounded by follicular cells. There are multiple tiny ringlets of follicular cells forming microfollicles.

You recommend thyroid surgery.

Which of the following is the most reasonable next step to perform preoperatively?

A. Repeated FNAB targeting the capsule of the nodule

B. 123I thyroid scan

C. Neck ultrasonography to evaluate cervical lymph nodes

D. Measurement of serum thyroglobulin

E. No further tests

Question 79

A 62-year-old man with a 10-year history of type 2 diabetes mellitus presents for cardiovascular evaluation. He has a history of cardiovascular disease, with a myocardial infarction that occurred at age 58 years. He also has a family history of heart disease. His current medications are lisinopril, 20 mg daily; metformin, 1000 mg daily; insulin lispro, 4 units before each meal; and insulin glargine, 20 units in the morning. He quit smoking 5 years ago after a 20 pack-year history. On physical examination, his seated blood pressure is 140/90 mm Hg and BMI is 30 kg/m2.

Recent laboratory test results:

  • Hemoglobin A1c = 6.8% (4.0%-5.6%) (SI: 51 mmol/mol [20-38 mmol/mol])
  • Fasting plasma glucose = 94 mg/dL (70-99 mg/dL) (SI: 5.2 mmol/L [3.9-5.5 mmol/L])
  • Total cholesterol = 189 mg/dL (<200 mg/dL [optimal]) (SI: 4.90 mmol/L [<5.18 mmol/L])
  • Triglycerides = 120 mg/dL (<150 mg/dL [optimal]) (SI: 1.36 mmol/L [<3.88 mmol/L])
  • LDL cholesterol = 135 mg/dL (<100 mg/dL [optimal]) (SI: 3.50 mmol/L [<0.59 mmol/L])
  • HDL cholesterol = 40 mg/dL (>60 mg/dL [optimal]) (SI: 1.04 mmol/L [>1.55 mmol/L])
Which of the following is the best treatment to address his lipid profile?

A. Pravastatin, 40 mg daily

B. Rosuvastatin, 20 mg daily

C. Lovastatin, 40 mg daily

D. Simvastatin, 20 mg daily

E. Atorvastatin, 10 mg daily

Question 80

An oncologist refers to you a 55-year-old man for evaluation of new-onset hypercalcemia. The patient has asymptomatic, diffuse bone lymphoma that has not required treatment. He describes experiencing malaise and fatigue.

Laboratory test results:

  • Serum calcium = 11.7 mg/dL (8.2-10.2 mg/dL) (SI: 2.9 mmol/L [2.1-2.6 mmol/L])
  • Albumin = 4.1 mg/dL (3.5-5.0 g/dL) (SI: 41 g/L [35-50 g/L])
  • Creatinine = 0.9 mg/dL (0.7-1.3 mg/dL) (SI: 79.6 µmol/L [61.9-114.9 µmol/L])
  • 25-Hydroxyvitamin D = 25 ng/mL (25-80 ng/mL [optimal]) (SI: 62.4 nmol/L [62.4-199.7 nmol/L])
  • 1,25-Dihydroxyvitamin D = 52 pg/mL (16-65 pg/mL) (SI: 135.2 pmol/L [41.6-169.0 pmol/L])
  • PTH = 5 pg/mL (10-65 pg/mL) (SI: 5 ng/L [10-65 ng/L])
  • PTHrP, undetectable
Which of the following is the best treatment for his hypercalcemia?

A. Cinacalcet

B. Treatment of the lymphoma

C. Oral furosemide

D. Subcutaneous calcitonin

E. Nasal calcitonin

Question 81

A 60-year-old man presents with a several-week history of polyuria and polydipsia. He reports no headache, but he does have double vision. He previously smoked 20 cigarettes per day for 30 years, but stopped 3 years ago. He has no notable medical history and takes no medications.

On physical examination, he appears thin and pale. His skin is dry. His height is 69 in (175.3 cm), and weight is 150 lb (68.2 kg) (BMI = 22.1 kg/m2). His blood pressure is 114/68 mm Hg, and resting pulse rate is 52 beats/min. Examination of his cranial nerves reveals a right VI nerve palsy.

A water-deprivation test confirms central diabetes insipidus. Thus, further investigation of pituitary function is ordered:

  • Cortisol (8 AM) = 24 ?g/dL (5-25 ?g/dL) (SI: 662.1 nmol/L [137.9-689.7 nmol/L])
  • TSH = 0.38 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 0.4 ng/dL (0.8-1.8 ng/dL) (SI: 5.1 pmol/L [10.30-23.17 pmol/L])
  • FSH = 0.2 mIU/mL (1.0-13.0 mIU/mL) (SI: 0.2 IU/L [1.0-13.0 IU/L])
  • LH = 0.4 mIU/mL (1.0-9.0 mIU/mL) (SI: 0.4 IU/L [1.0-9.0 IU/L])
  • Free testosterone = 4.0 ng/dL (9.0-30.0 ng/dL) (SI: 0.1 nmol/L [0.31-1.04 nmol/L])
  • Prolactin = 18.0 ng/mL (4.0-23.0 ng/mL) (SI: 0.8 nmol/L [0.17-1.00 nmol/L])
  • IGF-1 = 62.0 ng/mL (78-220 ng/mL) (SI: 8.1 nmol/L [10.2-28.8 nmol/L])

Pituitary MRI is performed (see image).


Sagittal view                                                     Coronal view

Which of the following is the most likely cause of pituitary pathology in this patient?

A. Pituitary macroadenoma

B. Craniopharyngioma

C. Meningioma

D. Pituitary metastasis

E. Rathke cleft cyst

Question 82

An 80-year-old man is admitted to the intensive care unit for overwhelming sepsis and multiorgan failure. Despite aggressive therapy, the patient’s condition continues to deteriorate. One month earlier, he had a normal thyroid laboratory panel.

Which of the following patterns is expected in this patient?

Answer

TSH

Total T4

Total T3

Free T4

A.

10.0 mIU/L

7.0 µg/dL
(90.1 nmol/L)

70 ng/dL
(1.1 nmol/L)

0.7 ng/dL
(9.0 pmol/L)

B.

7.5 mIU/L

5.5 µg/dL
(70.8 nmol/L)

55 ng/dL
(0.8 nmol/L)

0.8 ng/dL
(10.3 pmol/L)

C.

0.2 mIU/L

2.5 µg/dL
(31.2 nmol/L)

25 ng/dL
(0.4 nmol/L)

0.5 ng/dL
(6.4 pmol/L)

D.

5.0 mIU/L

12.0 µg/dL
(154.4 nmol/L)

70 ng/dL
(1.1 nmol/L)

2.2 ng/dL
(28.3 pmol/L)

E.

0.01 mIU/L

12.0 µg/dL
(154.4 nmol/L)

360 ng/dL
(5.5 nmol/L)

2.2 ng/dL
(28.3 pmol/L)

Reference ranges: TSH, 0.5-5.0 mIU/L; total T4, 5.5-12.5 µg/dL (91.02-213.68 nmol/L); total T3, 70-200 ng/dL (1.08-3.08 nmol/L); free T4, 0.8-1.8 ng/dL (10.30-23.17 pmol/L).

A. A

B. B

C. C

D. D

E. E

Question 83

A 29-year-old pregnant woman with partial diabetes insipidus from childhood head trauma is brought to the emergency department for generalized weakness and lethargy. She is 4 months pregnant. Because her diabetes insipidus was mild, she has always preferred to drink extra fluids rather than take medication. She also has Hashimoto thyroiditis and has been taking levothyroxine, 112 mcg daily. Before conceiving, she always had regular menses. Aside from this recent weakness and lethargy, she has been well. However, for the past 2 months she has noticed increasing polyuria and polydipsia with some nausea. For the past 5 days, she has had a sore throat, myalgias, and low-grade fever, all of which resemble the symptoms of some of her office coworkers.

On physical examination in the emergency department, the patient is semiobtunded with a blood pressure of 80/50 mm Hg and a pulse of 130 beats/min. She has dry mucous membranes with skin tenting.

Laboratory test results:

  • Serum sodium = 162 mEq/L (136-142 mEq/L) (SI: 162 mmol/L [136-142 mmol/L])
  • Urine specific gravity = 1.002
Which of the following is the most likely explanation for this woman’s clinical deterioration?

A. Sheehan syndrome

B. Failure to increase her thyroid hormone replacement appropriately for pregnancy

C. Pregnancy-induced exacerbation of subclinical anterior hypopituitarism

D. Lymphocytic hypophysitis

E. Increased metabolism of vasopressin by placental vasopressinase

Question 84

A 65-year-old man is being followed up for type 2 diabetes mellitus of several years’ duration. He is treated with metformin, 1000 mg twice daily. He has background retinopathy and microalbuminuria. Other than a BMI of 32.5 kg/m2, the rest of his examination findings are normal.

Laboratory test results:

  • Creatinine = 1.3 mg/dL (0.7-1.3 mg/dL) (SI: 114.9 µmol/L [61.9-114.9 µmol/L])
  • Fasting blood glucose = 175 mg/dL (70-99 mg/dL) (SI: 9.7 [3.9-5.5 mmol/L])
  • Hemoglobin A1c = 8.0% (4.0%-5.6%) (64 mmol/mol [20-38 mmol/mol])

Your discussion about alternative therapies turns to the use of exenatide in combination with metformin.

In this patient, exenatide therapy will most likely:

A. Unmask existing gastroparesis, resulting in nausea and vomiting

B. Cause hypoglycemia in combination with the patient’s current therapy

C. Produce clinically significant and sustained weight loss by increasing energy expenditure

D. Lower hemoglobin A1c by a combination of effects on insulin and glucagon secretion, as well as by increasing satiety

E. Carry a higher risk of pancreatitis than other therapies

Question 85

A 70-year-old man in whom American Joint Committee on Cancer stage III (T3,N0,M0) follicular thyroid cancer was diagnosed 5 years ago has just moved to your area and presents for a first visit. His initial treatment consisted of total thyroidectomy followed by radioactive iodine therapy with a 100-mCi dose of 131I. Postoperative histopathologic evaluation of the specimen documented a 4.1-cm widely invasive follicular thyroid carcinoma with numerous foci of vascular invasion. His posttherapy 131I whole-body scan demonstrated uptake in the thyroid bed only, and a recombinant TSH-stimulated radioiodine scan 12 months after his initial treatment was negative. Serial measurements of serum thyroglobulin and thyroglobulin antibodies are detailed (see table).

Date

Serum Thyroglobulin

Thyroglobulin Antibodies


Serum TSH

Recombinant TSH Stimulation

4 years ago

<0.1 ng/mL
(<0.1 μg/L)

<4.0 IU/mL
(<4.0 kIU/L)

<0.01 mIU/L

Yes

2 years ago

0.9 ng/mL
(0.9 μg/L)

<4.0 IU/mL
(<4.0 kIU/L)

<0.01 mIU/L

No

9 months ago

8.3 ng/mL
(8.3 μg/L)

<4.0 IU/mL
(<4.0 kIU/L)

<0.01 mIU/L

Yes

4 months ago

15.6 ng/mL
(15.6 μg/L)

<4.0 IU/mL
(<4.0 kIU/L)

<0.01 mIU/L

Yes

The results of a recombinant TSH-stimulated 131I whole-body scan performed 4 months ago are displayed (see image).

He has noticed some shortness of breath on exertion in recent months, but is otherwise feeling well. His only medication is levothyroxine, 150 mcg daily.

On physical examination, his blood pressure is 130/80 mm Hg, and pulse rate is 76 beats/min. There is no palpable thyroid tissue in the thyroid bed and no cervical adenopathy.

You perform cervical ultrasonography, which does not reveal any suspicious findings.

Laboratory test results:

  • TSH = <0.01 mIU/L (0.5-5.0 mIU/L)
  • Free T4 = 1.8 ng/dL (0.8-1.8 ng/dL) (SI: 23.2 pmol/L [10.30-23.17 pmol/L])
  • Serum thyroglobulin  = 22 ng/mL (<0.1 ng/mL) (SI: 22 µg/L [<0.1 µg/L])
  • Thyroglobulin antibodies = <4.0 IU/mL (?4.0 IU/mL) (SI: <4.0 kIU/L [?4.0 kIU/L])
Which of the following is the best next step in this patient’s care?

A. MRI of the neck with gadolinium contrast

B. CT of the neck with intravenous contrast

C. Repeated thyroglobulin measurement and cervical ultrasonography in 3 months

D. 18F-fluorodeoxyglucose PET imaging (FDG-PET)

E. Diagnostic whole-body radioiodine scan following recombinant TSH stimulation

Question 86

A 72-year-old man undergoes abdominal ultrasonography during the evaluation of newly discovered liver enzyme elevations. The study was normal except for the finding of an echogenic liver consistent with hepatic steatosis. He has a history of type 2 diabetes mellitus, obstructive sleep apnea, and hypertension and hyperlipidemia for which pravastatin was recently started. His review of systems is otherwise normal. There is no history of intravenous drug use, body piercing, or tattoos. He drinks 2 to 3 glasses of alcohol per week. Medications include glipizide, insulin glargine, pravastatin, lisinopril, and hydrochlorothiazide.

On physical examination, he is alert and fully oriented. His height is 70 in (177.8 cm) and weight is 243 lb (110.5 kg) (BMI = 34.9 kg/m2). There is no jaundice. His abdomen is soft, nondistended, and nontender. His liver and spleen are nonpalpable. There is no fluid wave. He has no clubbing or edema in the extremities. There is no palmar erythema.

Laboratory test results:

  • Hemoglobin A1c = 8.8% (4.0%-5.6%) (65 mmol/mol [20-38 mmol/mol])
  • LDL cholesterol = 68 mg/dL (<100 mg/dL [optimal]) (SI: 1.76 mmol/L [<0.59 mmol/L])
  • HDL cholesterol = 33 mg/dL (>60 mg/dL [optimal]) (SI: 0.85 mmol/L [>1.55 mmol/L])
  • Triglycerides = 257 mg/dL (<150 mg/dL [optimal]) (SI: 2.90 mmol/L [<3.88 mmol/L])
  • AST = 104 U/L (20-48 U/L) (SI: 1.7 µkat/L [0.33-0.80 µkat/L])
  • ALT = 127 U/L (10-40 U/L) (SI: 2.1  µkat/L [0.17-0.67 µkat/L])
  • Alkaline phosphatase = 182 U/L (50-120 U/L) (SI: 3.0 µkat/L [0.84-2.00 µkat/L])
  • Total bilirubin = 0.6 mg/dL (0.3-1.2 mg/dL) (SI: 10.3 µmol/L [5.1-20.5 µmol/L])
  • Albumin = 3.9 g/dL (3.5-5.0 g/dL) (SI: 39 g/L [35-50 g/L])
  • Creatinine = 1.3 mg/dL (0.7-1.3 mg/dL) (SI: 114.9 µmol/L [61.9-114.9 µmol/L])
  • INR = 0.92 (0.8-1.2)
  • Hepatitis B and C serologies, negative

Liver biopsy shows changes of hepatitis with steatosis, hepatocyte swelling, and mild acute lobular and chronic portal inflammation.

Which of the following interventions would you next advise in the management of this patient’s liver abnormalities?

A. Weight loss

B. Intensification of insulin therapy to improve hemoglobin A1c

C. Discontinuation of pravastatin

D. Initiation of fenofibrate

E. Elimination of alcohol intake

Question 87

A 51-year-old healthy woman presents with hot flashes, painful intercourse, and insomnia. She does not smoke cigarettes and has no history of venous thrombosis. There is no family history of breast cancer or colon cancer. Her physical examination findings are normal. Pelvic ultrasonography shows a normal uterus with a thin endometrial stripe and small ovaries without masses. She wishes to discuss the risks of menopausal hormone therapy.

Which of the following would be the most common increased risk for this woman if prescribed postmenopausal combined estrogen-progestin hormone therapy for 5 years?

A. Colon cancer

B. Dementia

C. Stroke

D. Deep venous thrombosis

E. Breast cancer

Question 88

A 23-year-old woman with a 15-year history of type 1 diabetes mellitus presents with a new skin lesion. She reports a nonpainful sore on her anterior left lower extremity that has enlarged over the past 3 months. On physical examination, you observe the lesion (see image).

Which of the following is the most likely diagnosis?

A. Erythema nodosum

B. Scleredema

C. Necrobiosis lipoidica

D. Necrolytic migratory erythema

E. Granuloma annulare

Question 89

A 39-year-old man is referred to you because of low bone mass identified at a health fair (bone density of the heel assessed by ultrasonography was low). He has no notable medical history, but he does have a family history of osteoporosis. He does not smoke cigarettes and does not consume much alcohol.

On physical examination, his blood pressure is 120/74 mm Hg and heart rate is 68 beats/min. His height is 69 in (175.3 cm), and weight is 180 lb (81.8 kg) (BMI = 26.6 kg/m2). Sclerae are white. He has no signs of Cushing syndrome, thyroid dysfunction, or ecchymoses, but he has a diffuse macular rash, especially on his trunk, with a positive Darier sign and associated pruritus. A photograph is shown.

DXA bone mineral density measurements:

Region

BMD, g/cm2

T score

Z score

L1-L4

0.746

–3.1

–3.0

Hip

0.847

–1.2

–0.8

Femoral neck

0.663

–2.0

–1.4

After reviewing normal values from a complete blood cell count and measurement of electrolytes, serum urea nitrogen, creatinine, calcium, and albumin, you order additional laboratory tests.

Which one of the following laboratory test results is most consistent with this clinical scenario?

A. Total testosterone = 98 ng/dL(300-900 ng/dL) (SI: 3.4 nmol/L [10.4-31.2 nmol/L])

B. 25-Hydroxyvitamin D = 22 ng/mL (25-80 ng/mL [optimal]) (SI: 54.9 nmol/L [62.4-199.7 nmol/L])

C. PTH = 65 pg/mL (10-65 pg/mL) (SI: 65 ng/L [10-65 ng/L])

D. Tryptase = 78 ng/mL (&lt;11.5 ng/mL) (SI: 78 µg/L [&lt;11.5 µg/L]

E. Calcitonin = 50 pg/mL (&lt;16 pg/mL) (SI: 14.6 pmol/L [&lt;4.67 pmol/L])

Question 90

A 29-year-old man is referred because a head CT performed in the emergency department after an automobile crash showed an empty sella, which was confirmed on a subsequent MRI examination of the pituitary. He was generally well before the accident. He states that he received GH injections for many years as a child and stopped when he completed growth at age 18 years. He has also taken thyroid hormone since age 12 years.

Which of the following is the most likely cause of his empty sella?

A. Trauma-induced pituitary infarction

B. PROP1 mutation

C. Burnt-out hypothalamic/pituitary sarcoidosis

D. Langerhans cell histiocytosis

E. Hemochromatosis