Clinical Diabetes and Endocrinology in 2017 Pre and Post Test Questions

Transcription

1 1) A 24 year old woman has experienced weakness, light headedness and 6 lb weight loss over the past 6 months. Her past history is unremarkable. Vital Signs: BP 90/65, Pulse 80, T PE: skin appears tanned. Initial Labs: Na 132 meq/l (nl: ) K 5.6 meq/l (nl: ) Creatinine 0.8 mg/dl (nl, ) Glucose 72 mg/dl (nl, ) Which of the following tests is most likely to yield the correct diagnosis? a. Plasma Aldosterone and Renin b. Urinary Catecholamines and Metanephrines c. Cosyntropin Stimulation Test d. 1 mg Dexamethasone Suppression Test e. Plasma ACTH 2) Which one of the following is correct about the use of FRAX to estimate 10 year fracture probability in men? a. FRAX for men in the USA is validated for only 4 ethnicities Caucasian, Black, Hispanic, Asian b. BMD input for FRAX is with either the femoral neck or total proximal femur c. If hip BMD is not evaluable, lumbar spine BMD may be used in its place d. T score calculated using a male reference database may be used in the algorithm 3) The most common cause of subclinical hyperthyroidism is: a. Graves disease b. Toxic multinodular goiter c. Excessive thyroxine dosing d. Physiologic changes in serum TSH with age 4 ) A 35 year old otherwise healthy man presents with questions regarding lab results from a local health fair. His total cholesterol is 290 mg/dl with triglycerides of 105 mg/dl, HDL cholesterol of 49 mg/dl and a calculated LDL cholesterol of 220 mg/dl. His family history is significant for a father who underwent a CABG procedure at the age of 54. His exam is normal. Which of the following lipid disorders is the most consistent diagnosis? a. A specific diagnosis cannot be made unless genetic testing is performed b. Familial Combined Hyperlipidemia c. Definite diagnosis of Heterozygous Familial Hypercholesterolemia d. Possible diagnosis of Heterozygous Familial Hypercholesterolemia e. Homozygous Familial Hypercholesterolemia 5) The next best step for this case is to: a. Initiate moderate intensity statin therapy b. Initiate high intensity statin therapy c. Initiate healthy lifestyle because his 10 year of ASCVD is not high enough to warrant statin therapy. d. Initiate a PCSK 9 inhibitor since his diagnosis most consistent with heterozygous familial hypercholesterolemia e. Initiate ezetimibe in addition to high intensity statin therapy in order to get his LDL cholesterol below a goal of < 70 mg/dl

2 6) Most adolescents with T1D with CVD risk factors above AHA/ADA treatment thresholds are on pharmacologic therapy. a. True b. False 7) A 70 year old man is referred for poor glucose control. He was diagnosed with diabetes 20 years ago and has been treated with insulin for the past 10 years. He has no microvascular complications, but had a myocardial infarction 8 years ago. His recent hemoglobin A 1c levels have been between 8.5% and 9.0%, and he has frequent nocturia. His primary care physician prescribed a regimen of glipizide, 10 mg daily, and NPH insulin, 40 units twice daily, which he takes before breakfast and his evening meal. Home glucose monitoring shows a mean fasting glucose concentration of 224 mg/dl. He reports waking in the middle of the night with sweating and intense hunger several times a month. On the basis of his age and comorbidities, you recommend a hemoglobin A 1c target of 8.0%. Which of the following adjustments to his insulin regimen is most likely to safely improve his glucose control? a. Increase the evening dose of NPH insulin to 46 units b. Increase the morning and evening insulin doses to 46 units c. Add 10 units of regular insulin to his premeal injections of 40 units of NPH; stop glipizide d. Add 15 units of regular insulin with 40 units of NPH before breakfast, 25 units of regular insulin before the evening meal, and 20 units of NPH before bed; stop glipizide e. Change his insulin regimen to 25 u of glargine before breakfast at at bedtime with 10 units of insulin aspart before each meal; stop glipizide 8) The risk of antithyroid drug induced angranulocytosis is approximately: a. 1/500 b. 1/1000 c. 1/5000 d. 1/10,000 9) A 71 year old woman is referred with newly diagnosed type 2 diabetes mellitus. She has longstanding hypertension, an admission for heart failure 5 years ago and a hip fracture with surgical treatment 2 years ago. Her hemoglobin A 1c level is 8.6%. A recent metabolic profile includes a serum creatinine concentration of 1.4 mg/dl and her estimated glomerular filtration rate is 54 ml/min. You decide to focus on a hemoglobin A 1c goal of 7.5%. Which of the following medications should be prescribed to treat her diabetes? a. Metformin b. Pioglitazone c. Dipeptidyl peptidase 4 inhibitor d. Glucagon like peptide 1 receptor agonist e. Glucosidase inhibitor 10) During the first year of testosterone therapy for a 25 year old trans man, which of the following changes would NOT be expected: a. Cessation of menses b. Decrease in triglycerides c. Weight gain d. Voice deepening

3 11) Combined hyperlipidemia is best defined by a. Genetic screening b. An increased non HDL C c. Total cholesterol >240 and TG>200 d. Fibrate trial 12) A 34 year old woman is admitted to the hospital for pyelonephritis. Vital Signs: BP 141/70, Pulse 144, T PE: diffuse goiter. Initial Labs: TSH < 0.1 mu/l Which of the following interventions will immediately reduce thyroid hormone release from the thyroid gland? a. Propylthiouracil b. Potassium Iodide c. Hydrocortisone d. Esmolol e. Diltiazem 13) A 29 year old woman has developed florid features of Cushing syndrome towards the end of her first trimester of pregnancy. She has developed hypertension, diabetes mellitus, hirsutism and wide, purple striae on her abdomen. Her morning serum cortisol is 37 μg/dl, her ACTH is 129 pg/ml and her urine free cortisol is 475 mg/24h. An MRI shows a 6 mm pituitary adenoma. Which one of the following treatment options is contraindicated in this setting? a. Ketoconazole b. Transsphenoidal surgery c. Mifepristone d. Metyrapone e. Cabergoline 14) The best test to rule out cancer in a patient with an indeterminate thyroid nodule cytology is one with: a. Low sensitivity and negative predictive value (NPV) b. High sensitivity and negative predictive value (NPV) c. Low specificity and positive predictive value (PPV) d. High specificity and positive predictive value (PPV) 15) Which one of the following is correct about romosozumab, an investigational compound for the treatment of osteoporosis? a. This is a synthetic analog to PTHrP(1 34) b. It is a fully human monoclonal antibody to DKK1 c. It is a humanized monoclonal antibody to sclerostin d. It increases BMD due to reduction of bone remodeling 16) A 46 year old man presents for advice on treatment of type 2 diabetes mellitus. He has been treated with metformin for 4 years, since an elevated blood glucose concentration was detected on a preoperative evaluation. His glucose control has varied, and a sulfonylurea was added last year when his hemoglobin A 1c increased to greater than 8.0%. However, he gained 5 kg with this treatment and stopped the drug after 6 months. He is otherwise healthy and his only medications are metformin and lisinopril. On physical examination, his BMI is 33 kg/m 2, and his blood pressure is 138/84 mm Hg. A repeated hemoglobin A 1c measurement is 8.4%.

4 Which of the following treatments is the best option for this man? a. Repaglinide b. Sitagliptin c. Liraglutide d. Pioglitazone e. Insulin glargine 17) While of the following properties is NOT a property of a stem cell: a. Can live forever b. Are capable of self renewal c. Can differentiate into multiple types of specialized tissues d. Can be derived from embryonic or adult tissues e. Can potentially be used in diagnosis and/or treatment of disease 18) Per Endocrine Society Guidelines for transwomen, which type of estrogen should be avoided? a. Oral 17 B estradiol b. Transdermal 17 B estradiol c. Oral ethinyl estradiol d. Estradiol valerate 19) According to the 2015 ATA guidelines on thyroid nodules and DTC, what is the recommended approach to a patient with a 2.8 cm thyroid nodule on ultrasound (no abnormal LN seen) that is PTC on FNA? a. Lobectomy only b. Lobectomy or thyroidectomy c. Thyroidectomy d. Thyroidectomy plus prophylactic central LN dissection 20) A 34 year old woman with type 2 diabetes (HbA1c 7.2%), hypertension, depression, and obesity (BMI 37) presents for an initial clinic visit with you to establish care. She does not have a known history of atherosclerotic cardiovascular disease. She has gained 30 pounds over the last 2 years and has not been able to lose it despite tracking her calorie intake and walking for 1 hour a day. She wants to start a medication for weight loss and realizes that they may not be covered by her insurance plan. You recommend: a. Phentermine b. Liraglutide c. Lorcaserin d. Naltrexone/bupropion e. Phentermine/topiramate 21) What of the following factors have been suggested as beta cell growth factors? (select as many as relevant) a. Thyroid hormone, GLP 1 and its analogues, and the protease inhibitor serpin B1 b. Thyroid hormone, GLP 1 and its analogues, and the angiotensin receptor blocker losartan c. Glucose, thyroid hormone, and the angiotensin receptor blocker losartan d. Glucose, GLP 1 and its analogues, and the protease inhibitor serpin B1 22) The risk of malignancy in a patient with a thyroid nodule having AUS/FLUS cytology is: a. 50% b. 5 10% c. <1%

5 d. 5 30% 23) Which of the following is correct about the treatment of osteoporosis in men? a. Alendronate increases BMD in eugonadal but not hypogonadal men b. Denosumab is the only drug approved to increase bone mass in men at high risk for fracture on androgen deprivation therapy for non metastatic prostate cancer c. Mortality after hip fracture is lower in men than in women d. Ibandronate is approved for the treatment of glucocorticoid induced osteoporosis in transgender men 24) Which one of the following statements about islets is not true? a. Represent the major site of insulin and glucagon production b. Are themselves an insulin responsive tissue c. Can be altered in diabetes in both quantity (mass) and function (insulin secretion) d. Along with the acinar (digestive enzyme secreting) pancreas, are altered in diabetes e. Can respond to insulin resistance with increase in growth 25) What are the major tissues where insulin resistance can drive and increase in beta cells growth? (select as many as relevant) a. Muscle and liver b. Liver and fat c. Brain and liver d. Brain and endothelial cells 26) You are seeing a 53 year old man with a 12 year history of type 2 diabetes. His point of care HbA1c in the clinic was 8.4%, and he is on metformin XR 2000 mg QD, glipizide XL 20 mg, and insulin glargine 35 units QD. He works the night shift as a security guard from Thursdays to Mondays. Upon further questioning, he admits that he sometimes misses or delays his insulin dose, usually after he comes home after work. What would be a good next step? a. Increase his dose of glargine b. Start lispro insulin with his largest meal of the day c. Switch to insulin detemir d. Switch to insulin degludec e. Increase the glipizide dose 27) RCTs have indicated that combined hyperlipidemia should be best treated with a statin + a. Heart healthy lifestyle b. Fibrate c. Niacin d. EPA e. None of the above 28) A 24 year old man is referred for evaluation of gynecomastia. He describes normal libido and erections, but he has had painless breast enlargement since puberty. He shaves weekly and has relatively sparse body hair. His medical history is remarkable for primary hypothyroidism due to Hashimoto thyroiditis. His family medical history is remarkable for multiple sclerosis in his mother. On physical examination, height is 72 in (183 cm) and BMI is 23 kg/m 2. He has sparse facial hair, normal axillary hair, and Tanner stage 4 pubic hair. There is 4 cm bilateral gynecomastia with no galactorrhea. He has a normal phallus with no hypospadias. His testes are small and firm, measuring 5 ml bilaterally. Laboratory test results: Total testosterone = 170 ng/dl (reference range, ng/dl) FSH = 48 miu/ml (48 IU/L) (reference range, miu/ml [ IU/L])

6 LH = 27 miu/ml (27 IU/L) (reference range, miu/ml [ IU/L]) Which of the following tests would be most useful to determine this patient s diagnosis? a. Serum iron studies including iron saturation b. Measurement of inhibin B concentration c. Karyotype analysis d. Assessment of anti testis antibodies e. Assessment of androgen receptor CAG repeat number 29) What % of children and adolescents with T1D have an A1c below the target of 7.5%? a. 12% b. 25% c. 47% d. 60%