ESAP-ITE 2018 Test Item Detail Report

Transcription

1 ESAP-ITE 2018 Test Item Detail Report 1) A 45-year-old man with a 5-year history of type 2 diabetes mellitus presents to the emergency department with worsening fatigue and is found to have acute renal injury. His creatinine concentration on presentation is 3.5 mg/dl (309.4 µmol/l); review of his outpatient records shows his creatinine concentration was 1.8 mg/dl (159.1 µmol/l) 6 months ago. The patient reports having a CT with contrast 1 week ago to follow-up on a nonspecific finding on previous imaging. He has had no nausea or vomiting. His current insulin regimen consists of premixed 70/30 insulin, 30 units in the morning and 30 units with his evening meal. He also takes metformin, 1000 mg twice daily. His blood glucose readings at home, prior to the CT, were 150 to 180 mg/dl ( mmol/l). On physical examination, his height is 70 in (177.8 cm) and weight is 200 lb (90.9 kg) (BMI = 28.7 kg/m 2 ). Laboratory test results on admission: Hemoglobin A 1c = 8.0% (4.0%-5.6%) (64 mmol/mol [20-38 mmol/mol]) Estimated glomerular filtration rate = 30 ml/min per 1.73 m2 (>60 ml/min per 1.72 m2) Glucose = 120 mg/dl (70-99 mg/dl) (SI: 6.7 mmol/l [ mmol/l]) The patient is admitted to a general medicine ward. In addition to holding metformin, which of the following scheduled insulin regimens should you recommend? Answer Daily Basal Insulin Prandial Insulin (per meal) Blood Glucose Target A. 30 units 10 units mg/dl ( mmol/l) B. 22 units 5 units mg/dl ( mmol/l) C. 22 units 7 units mg/dl ( mmol/l) D. 15 units 5 units mg/dl ( mmol/l) E. 30 units 10 units mg/dl ( mmol/l) A. A B. B C. C D. D E. E

2 2) A 54-year-old man makes an appointment to discuss hyperlipidemia. He has a history of focal segmental glomerulosclerosis causing progressive renal failure and he recently started hemodialysis. He is being assessed for possible renal transplant. He does not smoke cigarettes. He has longstanding hypertension (controlled on 3 medications) and a family history of cardiovascular disease in his father and paternal uncle who had myocardial infarctions at age 52 years and 48 years, respectively. On physical examination, his height is 73 in (185.4 cm) and weight is 195 lb (88.6 kg) (BMI = 25.7 kg/m 2 ). His blood pressure is 128/64 mm Hg, and pulse rate is 74 beats/min. Laboratory test results (fasting): Total cholesterol = 200 mg/dl (<200 mg/dl [optimal]) (SI: 5.18 mmol/l [<5.18 mmol/l]) LDL cholesterol = 158 mg/dl (<100 mg/dl [optimal]) (SI: 4.09 mmol/l [<2.59 mmol/l]) HDL cholesterol = 32 mg/dl (>60 mg/dl [optimal]) (SI: 0.83 mmol/l [>1.55 mmol/l]) Triglycerides = 176 mg/dl (<150 mg/dl [optimal]) (SI: 1.99 mmol/l [<1.70 mmol/l]) He wants to know whether he should start a statin to reduce his cardiovascular risk. Which of the following should you recommend? A. Start a statin; he will have the same relative risk reduction as that of a patient with normal renal function B. Start a statin; however, his relative risk reduction is less than that of a patient without chronic kidney disease C. Start a statin; specifically, simvastatin no other statin has been shown to reduce cardiovascular risk in patients with chronic kidney disease D. Do not start a statin; it has no cardiovascular benefit in this patient E. Do not start a statin; it is contraindicated in this patient 3) A 69-year-old woman in whom stage III papillary thyroid cancer was diagnosed 15 years ago has just moved to your area and presents for an initial visit. Her initial therapy consisted of thyroidectomy and radioiodine administration. The pathology from her surgery had documented a 3-cm papillary cancer with involvement of left central and left lateral cervical nodes. She had been monitored with recombinant TSH-stimulated radioiodine scanning and thyroglobulin measurement on 2 occasions (1 and 3 years after her diagnosis). She has had periodic cervical ultrasonography that has not revealed any suspicious thyroid bed lesions or cervical lymph nodes. Review of her past laboratory testing shows that thyroglobulin has been consistently undetectable and her TSH concentration has been between 0.01 and 0.09 miu/l. She has no specific concerns except for difficulty sleeping characterized by early awakening and inability to get back to sleep. She has osteoporosis treated with a bisphosphonate, but no other medical problems. Her levothyroxine dosage is 137 mcg daily (2.3 mcg/kg as a weight-based dosage). On physical examination, there is no palpable tissue in the thyroid bed and no cervical adenopathy. TSH = 0.09 miu/l ( miu/l) Free T 4 = 1.8 ng/dl ( ng/dl) (SI: 23.2 pmol/l [ pmol/l]) Serum thyroglobulin = <0.1 ng/ml (<1.0 ng/ml) (SI: <0.1 µg/l [<0.1 µg/l]) Antithyroglobulin antibodies, negative Cervical ultrasonography shows absence of tissue in the thyroid bed and some subcentimeter, benign-appearing lymph nodes bilaterally. Which of the following is the best management plan? A. Reduce the levothyroxine dosage to 112 mcg daily B. Reduce the levothyroxine dosage to 112 mcg daily and add liothyronine, 5 mcg daily C. Continue the current levothyroxine dosage D. Continue the current levothyroxine dosage and add a β-adrenergic blocker

3 E. Order a recombinant TSH-stimulated whole-body radioiodine scan and thyroglobulin measurement 4) You are asked to see a 38-year-old woman who underwent successful transsphenoidal resection of a nonfunctioning pituitary adenoma 6 months ago. Postoperative endocrine testing demonstrated anterior pituitary dysfunction, and the following medications were prescribed: hydrocortisone, 25 mg daily in divided doses; levothyroxine, 150 mcg daily; and a combined oral contraceptive pill (norethindrone and ethinyl estradiol, 1/35). She has 2 children, aged 10 and 12 years, and she had a tubal ligation after her second child was born. She has been experiencing regular and predictable withdrawal bleeds since starting the oral contraceptive pill. Despite good adherence to her treatment regimen, she continues to experience lethargy, general malaise, and low mood. On physical examination, she appears well. Her height is 66 in (167.6 cm), and weight is 141 lb (64.1 kg) (BMI = 22.8 kg/m 2 ). Her blood pressure is 124/79 mm Hg (supine) with no notable postural drop. She appears euthyroid. Sodium = 137 meq/l ( meq/l) (SI: 137 mmol/l [ mmol/l]) Potassium = 4.4 meq/l ( meq/l) (SI: 4.4 mmol/l [ mmol/l]) Creatinine = 0.7 mg/dl ( mg/dl) (SI: 61.9 µmol/l [ µmol/l]) TSH = 2.1 miu/l ( miu/l) Free T 4 = 1.4 ng/dl ( ng/dl) (SI: 18.0 pmol/l [ pmol/l]) GH = <0.01 ng/ml ( ng/ml) (SI: <0.01 mg/l [ mg/l]) IGF-1 = <50 ng/ml ( ng/ml) (SI: 6.6 nmol/l [ nmol/l]) DHEA-S = 14 µg/dl ( µg/dl) (SI: 0.38 µmol/l [ µmol/l]) GH therapy is initiated. Which of the following adjustments to her current endocrine therapy may be required? A. No adjustment required B. Reduce the hydrocortisone dosage C. Switch from the combined oral contraceptive pill to transdermal estrogen and progestin D. Reduce the levothyroxine dosage E. Add DHEA 5) You are seeing a 73-year-old man who has been treated with alendronate, 70 mg weekly, for 2 years. His recent DXA scan shows a femoral neck T score of 2.7 and no change in bone mineral density compared with findings from 2 years ago. He says he is 3 in (7.6 cm) shorter than his young adult height, but he does not know whether his height has changed over the past few years. Vertebral fracture assessment shows a compression fracture of L1. For the past several years, he has had back pain almost every day, some days more than others, but he does not recall an incident that might explain this finding. Which of the following tests is most likely to give useful information regarding the age of this fracture if it occurred more than 6 months ago? A. Bone-specific alkaline phosphatase measurement B. Lumbar spine radiograph C. MRI D. CT E. Nuclear medicine bone scan 6) A 72-year-old man is referred to you by his primary care physician because of abnormal thyroid function test results and a right-sided neck mass. The patient reports no symptoms of thyroid dysfunction and was not aware of the neck mass until his physician noted it. On physical examination, his blood pressure is 134/76 mm Hg and pulse rate is 76 beats/min. Examination of his neck confirms a right-sided neck mass (2 cm in maximal diameter) that moves with swallowing. There is no palpable cervical

4 lymphadenopathy. There is no tremor and no obvious signs of thyroid-related ophthalmopathy. TSH = 0.06 miu/l ( miu/l) Free T 4 = 1.6 ng/dl ( ng/dl) (SI: 20.6 pmol/l [ pmol/l]) Free T 3 = 4.0 pg/ml ( pg/ml) (SI: 6.1 pmol/l [ pmol/l]) In view of the low TSH level, a technetium 99mTc pertechnetate scan is performed (see images). Thyroid ultrasonography is also performed (see images). This confirms a dominant mixed cystic/solid right-sided nodule (16 x 20 x 23 mm) with internal colloid. On the left side, there is a solid, isoechoic nodule (14 x 15 x 12 mm) with no microcalcifications and no internal blood flow. Which of the following is the best next step in this patient s management? A. Ultrasound-guided FNAB of both right- and left-sided thyroid nodules B. Ultrasound-guided FNAB of the right-sided thyroid nodule C. Ultrasound-guided FNAB of the left-sided thyroid nodule D. Treatment with 131 I radioactive iodine E. Measurement of serum thyroid-stimulating immunoglobulin 7) A 54-year-old man is referred for evaluation of fatigue and possible Cushing syndrome. His problems started after a back injury at work 1 year ago. He developed sudden lower back pain while lifting a heavy load and was sent home. He was evaluated and prescribed physical therapy for 6 weeks with some relief, and then he was given monthly back injections in a pain clinic for 6 months (the last treatment was 4 months ago). The injections markedly eased his pain, but he developed rapid weight gain, hunger, easy bruising, and facial fullness. His initial evaluation with his primary care physician documented the following laboratory values: Plasma ACTH = 4 pg/ml (10-60 pg/ml) (SI: 0.9 pmol/l [ pmol/l]) Urinary free cortisol = <3 µg/24 h (4-50 µg/24 h) (SI: <8.3 nmol/d [ nmol/d]) Overnight 1-mg dexamethasone suppression test, cortisol = <0.2 µg/dl (SI: <5.5 nmol/l) The patient is referred to you for further evaluation. He reports that his condition has not changed over the last 6

5 months. On physical examination, he has facial plethora and fullness, prominent supraclavicular fat pads, and dermal atrophy with diffuse bruising. His blood pressure is 130/80 mm Hg. His visual fields are full, and he has no pedal edema. Which of the following diagnostic tests will reveal the etiology of his Cushing syndrome? A. Late-night salivary cortisol measurement B. MRI-directed pituitary with contrast C. 111 In-pentetreotide ( octreotide ) scan D. CT scan with fine cuts of the adrenal glands E. Urine synthetic glucocorticoid testing 8) You are asked to see a 64-year-old woman who was found to have an elevated serum PTH level of 87 pg/ml (10-65 pg/ml) (SI: 87 ng/l [10-65 ng/l]) as part of an evaluation for low bone mass (lowest T scores, 2.1 in the spine and 1.6 in the left femoral neck) documented on routine DXA testing. Her BMI is 32 kg/m2. She has been taking 2000 IU of vitamin D daily for several years, and her daily calcium intake is from a balanced diet that includes 3 cups of milk per day without calcium supplements. Her serum calcium levels have consistently ranged between 9.3 and 10.0 mg/dl ( mmol/l), within the laboratory s reference range. Other laboratory test results: Serum 25-hydroxyvitamin D = 48 ng/ml (25-80 ng/ml [optimal]) (SI: nmol/l [ nmol/l]) Serum creatinine = 1.1 mg/dl ( mg/dl) (SI: 97.2 µmol/l [ µmol/l]) Repeated PTH = 79 pg/ml (10-65 pg/ml) (SI: 79 ng/l [10-65 ng/l]) Which of the following is the most appropriate next step? A. Order a sestamibi parathyroid scan B. Measure 24-hour urinary calcium and creatinine C. Increase the vitamin D dosage and measure PTH in 3 months D. Start calcium carbonate 500 mg twice daily and measure PTH in 6 months 9) A 64-year-old woman calls your office with concerns about her medications. She recently started a new diet that is heavy in fruits, including a daily glass of grapefruit juice for breakfast every day. She recalls the pharmacist telling her that she cannot take statins if she eats grapefruit. She had a myocardial infarction followed by coronary artery bypass grafting 3 years ago and she has since been taking atorvastatin, 40 mg daily. She has hypertension controlled with metoprolol. She is obese but is otherwise healthy. At her last visit, her weight was 186 lb (84.5 kg) and height was 64 in (162.6 cm) (BMI = 31.9 kg/m 2 ). Recent laboratory test results (fasting) while on atorvastatin (but before starting the grapefruit diet): Total cholesterol = 142 mg/dl (<200 mg/dl [optimal]) (SI: 3.68 mmol/l [<5.18 mmol/l]) HDL cholesterol = 42 mg/dl (>60 mg/dl [optimal]) (SI: 1.09 mmol/l [>1.55 mmol/l]) LDL cholesterol = 69 mg/dl (<100 mg/dl [optimal]) (SI: 1.79 mmol/l [<2.59 mmol/l]) Triglycerides = 98 mg/dl (<150 mg/dl [optimal]) (SI: 1.11 mmol/l [<1.70 mmol/l]) Creatinine = 0.7 mg/dl ( mg/dl) (SI: 61.9 µmol/l [ µmol/l]) ALT = 28 U/L (10-40 U/L) (SI: 0.47 µkat/l [ µkat/l]) Which of the following should be your advice? A. Discontinue statin therapy B. Stop the statin and start alirocumab C. Stop the statin and start a fibrate

6 D. Stop the statin and start ezetimibe E. Continue the current statin at the same dosage 10) A 19-year-old woman is referred to you for assistance with type 1 diabetes management. Diabetes was diagnosed at age 10 years. Her current insulin regimen includes insulin glargine, 10 units in the morning and 5 units in the evening. She boluses insulin aspart before meals using an insulin-to-carbohydrate ratio of 1 unit for each 15 g of carbohydrate and a sensitivity factor of 1 unit to lower her glucose 100 mg/dl (5.55 mmol/l) to a target level of 100 mg/dl (5.55 mmol/l). She participates in aerobic exercises for 60 to 90 minutes daily and weight training for 30 minutes 3 times per week. Her diet is rich in fruits, vegetables, lean meats, and mostly high-fiber carbohydrates. She feels comfortable with carbohydrate counting when eating at home, but has more difficulty accurately assessing the carbohydrate content of foods eaten at restaurants. She measures her glucose level 4 to 8 times daily. Her downloaded glucose meter shows glucose concentrations that range from 42 to 493 mg/dl (2.33 to mmol/l) with a mean of 168 mg/dl (9.32 mmol/l) and a standard deviation of 76 mg/dl (4.22 mmol/l). Glucose levels are least variable after eating a similar daily breakfast and are quite variable throughout the rest of the day. She senses that her glucose levels are low when they fall below 60 mg/dl (3.33 mmol/l) because she feels different. She has not had any episodes of severe hypoglycemia requiring assistance. Physical examination findings are unremarkable. Hemoglobin A 1c = 7.6% (4.0%-5.6%) (60 mmol/mol [20-38 mmol/mol]) LDL cholesterol = 52 mg/dl (<100 mg/dl [optimal]) (SI: 1.35 mmol/l [<2.59 mmol/l]) Urinary albumin-to-creatinine ratio = 7 mg/g creat (<30 mg/g creat) The patient asks whether insulin pump therapy would assist with her diabetes control. Which of the following outcomes would be most likely if this patient s insulin regimen were changed to insulin pump therapy? A. Reduced hemoglobin A1c B. Reduced flexibility in the timing of her meals C. Reduced risk of diabetic ketoacidosis D. Increased total daily insulin dose requirement E. No change in the risk of microvascular complications 11) An 18-year-old man is referred by his pediatric endocrinologist to establish care with you. He comes with his mother who tells you that he was diagnosed with Prader-Willi syndrome at age 3 years. As a baby, he had feeding difficulties due to poor muscle tone, but his appetite increased as he got older. His mother must constantly monitor his food intake. She reports that he is hungry all the time and she has resorted to locking kitchen cabinets to ensure he does not have access to food. He takes no medications. On physical examination, his blood pressure is 120/85 mm Hg, pulse rate is 60 beats/min, and BMI is 41 kg/m 2. The rest of his examination findings are unremarkable. During the visit, you discuss the endocrinopathies associated with his medical condition. The patient and his mother are very concerned about his weight and would like to learn about weight-loss options. Which of the following would you recommend to manage his obesity? A. Biliopancreatic diversion B. Roux-en-Y gastric bypass C. Topiramate

7 D. Leptin E. Referral to a dietitian for guidance on a supervised and restricted diet 12) You are asked to see a 45-year-old man with a history of type 2 diabetes mellitus for routine follow-up. He feels well and has no acute concerns. You have been encouraging his efforts at lifestyle changes with the hope of achieving some weight loss. His weight of 244 lb (110.9 kg) has been stable over the past year. He is otherwise healthy. He comments that he was relieved when he recently heard on the news that lifestyle changes do not really help people with type 2 diabetes, and he asks whether he must continue his activity program of walking 30 minutes 4 to 5 times per week. He currently takes metformin, 2000 mg daily; simvastatin, 20 mg daily; and lisinopril, 20 mg daily. On physical examination, he appears well. His height is 70 in (177.8 cm), and weight is 244 lb (110.9 kg) (BMI = 35 kg/m 2 ). His blood pressure is 138/80 mm Hg. Hemoglobin A 1c = 6.8% (4.0%-5.6%) (51 mmol/mol [20-38 mmol/mol]) Serum creatinine = 1.0 mg/dl ( mg/dl) (SI: 88.4 mmol/l [ mmol/l]) In this patient, intensive lifestyle changes (goals of weight loss of >7% and 175 minutes of moderate-intensity activity per week) would be expected to decrease which of the following? A. Risk of nonfatal stroke B. Risk of nonfatal cardiac events C. Risk of fatal cardiac events D. Risk of developing diabetic microvascular disease E. Need for insulin therapy 13) A 29-year-old man presented with severe thyrotoxicosis 1 year ago. His presentation was complicated by severe orbitopathy and schizophrenia for which he had recently stopped taking his prescribed medications. His endocrinologist recommended that he undergo thyroidectomy, but he elected to be treated with antithyroid medications. He initially required 60 mg of methimazole daily to control his hyperthyroidism. Since then, his thyroid status has varied considerably with periods of both undertreatment and overtreatment. Recently, he has been euthyroid while taking 5 mg of methimazole daily. The patient would now like to begin a trial off methimazole to see if he can remain euthyroid. He currently has no symptoms of hyperthyroidism. His other medications include risperidone for schizophrenia and cholecalciferol for vitamin D deficiency. On physical examination, his blood pressure is 108/76 mm Hg and pulse rate is 88 beats/min. He has moderate proptosis, but no signs of active ophthalmopathy. His thyroid gland is slightly enlarged, but he has no bruit. His deep tendon reflexes are normal. His thyroid function test results at the time of diagnosis and current values are shown (see table). Time of Assessment Measurement At Diagnosis Now TSH <0.001 miu/l 1.6 miu/l Free T 4 >7.0 ng/dl 1.5 ng/dl (90.1 pmol/l) (19.3 pmol/l) Total T 3 >800 ng/dl 140 ng/dl (12.3 pmol/l) (2.2 nmol/l) Thyroid-stimulating 400% 290%

8 immunoglobulin Reference ranges: TSH, miu/l; free T 4, ng/dl (SI: pmol/l); total T 3, ng/dl (SI: nmol/l); thyroid-stimulating immunoglobulin, 120% of basal activity. Which of the following factors most directly predicts the likelihood that this patient will experience relapse of his Graves disease while off antithyroid medication? A. Vitamin D deficiency B. Initial requirement for 60 mg methimazole C. Variable adherence to taking medications D. Orbitopathy E. Current thyroid-stimulating immunoglobulin titer 14) A 32-year-old man is referred for management of chemotherapy-related primary hypogonadism. He initially presented to his primary care physician 6 months ago with fatigue and decreased libido. After appropriate workup, intramuscular testosterone enanthate, 200 mg every 2 weeks, was initiated. Although he is better overall, he is bothered by fluctuation in his mood that occurs a few days before his next injection. He also experiences fatigue at the same time. On physical examination, his vital signs are normal. Testicular volume is 14 ml bilaterally. Testosterone (1 week after testosterone injection) = 767 ng/dl ( ng/dl) (SI: 26.6 nmol/l [ nmol/l]) Hematocrit = 42.2% (41%-50%) (SI: [ ]) Prostate-specific antigen = 1.0 ng/ml (<2.0 ng/ml) (SI: 1.0 µg/l [<2.0 µg/l]) Which of the following is the best next step in this patient s management? A. Change the current regimen to 400 mg every 4 weeks B. Change the current regimen to 100 mg every week C. Switch to testosterone cypionate at the current dosage D. Continue the current regimen with reassurance 15) A 37-year-old woman with no notable medical history except for hysterectomy 5 years ago (after the birth of her second child) started developing headaches about 4 months ago. Initial head CT was normal. Over the following 2 months, her headaches became worse, and she developed panhypopituitarism, including diabetes insipidus. Brain MRI showed diffuse enlargement of the pituitary gland and stalk thickening (4 mm). Lymphocytic hypophysitis was presumptively diagnosed, and she was treated with high-dosage dexamethasone, 4 mg twice daily. Now, 2 months later, her headaches have not improved. Her vision remains subjectively normal. She has no fever or chills. She has gained 20 lb (9.1 kg) since starting dexamethasone. Her pituitary mass has further enlarged. In addition to dexamethasone, she takes levothyroxine, 100 mcg daily, and desmopressin, 0.2 mg twice daily orally, with good control of polyuria. On physical examination, her height is 65 in (165 cm) and weight is 196 lb (89 kg) (BMI = 32.6 kg/m 2 ). Her blood pressure is 124/78 mm Hg, and pulse rate is 89 beats/min. She is afebrile. She has normally pigmented skin, normal findings on neurologic examination, and no tremors. Chest x-ray is normal. Which of the following is the most appropriate next step? A. Perform a pituitary biopsy B. Perform a tuberculin skin test

9 C. Measure transferrin saturation and ferritin D. Measure serum angiotensin-converting enzyme levels E. Measure pituitary antibodies 16) You are consulted regarding the management of a thyroid nodule in a 38-year-old man. Thyroid ultrasonography showed a cm right-sided nodule. The nodule was described as solid with a central hypoechoic region. FNAB of the nodule was performed, and cytologic examination documented a Hurthle-cell nodule, with a differential diagnosis including Hurthle-cell adenoma vs Hurthle-cell carcinoma. The patient has no other medical conditions. He has no compressive symptoms. On physical examination, his right thyroid lobe is clearly visible. The right-sided nodule is firm, nontender, and not associated with any other palpable nodules or lymphadenopathy. There is no apparent tracheal deviation. The rest of his physical examination findings are unremarkable. The sonographic appearance of the 4.9-cm nodule is shown (see image). Which of the following courses of action would you recommend to this patient and his primary care physician? A. Repeated thyroid ultrasonography in 1 year B. Repeated FNAB of the 4.9-cm nodule with Gene Expression Classifier testing C. Percutaneous ethanol injection into the 4.9-cm nodule D. Right lobectomy 17) An otherwise healthy 20-year-old African American man comes to clinic for a follow-up visit. He was hospitalized for treatment of diabetic ketoacidosis 4 months ago. Laboratory test results at hospital admission: Plasma glucose = 748 mg/dl (70-99 mg/dl) (SI: 41.5 mmol/l [ mmol/l]) Bicarbonate = 10 meq/l (21-28 meq/l) (SI: 10 mmol/l [21-28 meq/l]) Anion gap = 22 meq/l (3-11 meq/l) Creatinine = 2.2 mg/dl ( mg/dl) (SI: µmol/l [ µmol/l]) Estimated glomerular filtration rate = 34 ml/min per 1.73 m 2 (>60 ml/min per 1.73 m 2 ) Moderate ketones present in the serum No obvious cause of the diabetic ketoacidosis was found. He was treated with intravenous fluids and a continuous insulin infusion. The acidosis resolved and he was discharged on basal-bolus insulin. The total insulin dose at the time of discharge was 1.0 units/kg per day. The insulin doses have been gradually reduced over time. He is now administering 12 units of insulin glargine at

10 bedtime and 3 units of insulin aspart before each meal. The 2-week average glucose value is 107 mg/dl (5.9 mmol/l). The fasting glucose values range from 79 to 106 mg/dl ( mmol/l). He has no other medical problems. He does not have hypertension or dyslipidemia. He does not drink alcohol or smoke cigarettes. His mother, 2 of his 4 siblings, and several other maternal relatives have a history of diabetes. On physical examination, his height is 73 in (185 cm) and weight is 242 lb (110 kg) (BMI = 31.9 kg/m 2 ). His blood pressure is 122/83 mm Hg, and pulse rate is 82 beats/min. He has central weight distribution. There is evidence of acanthosis nigricans. The rest of the examination findings are normal. Current laboratory test results (fasting): Hemoglobin A 1c = 5.8% (4.0%-5.6%) (40 mmol/mol [20-38 mmol/mol]) Creatinine = 1.3 mg/dl ( mg/dl) (SI: µmol/l [ µmol/l]) Estimated glomerular filtration rate = >60 ml/min per 1.73 m 2 (>60 ml/min per 1.73 m 2 ) Electrolytes, normal TSH, normal C-peptide = 3.2 ng/ml ( ng/ml) (SI: 1.06 nmol/l [ nmol/l]) Glucose = 124 mg/dl (70-99 mg/dl) (SI: 6.9 mmol/l [ mmol/l]) Glutamic acid decarboxylase antibodies, undetectable Which of the following is the best next step in treating this patient s diabetes? A. Stop insulin aspart and start empagliflozin B. Stop insulin aspart and start glimepiride C. Stop all insulin and start metformin D. Stop all insulin and instruct the patient to continue diet treatment alone E. Continue the current insulin regimen 18) You are consulted regarding a 74-year-old man in the orthopedic unit 4 days after a left total hip replacement. The patient reported severe left flank discomfort for 24 hours and abdominal CT was performed (see image). Bilateral adrenal enlargement was noted (arrows). His medical team now seeks your consultation. He has been ambulatory since surgery, but his appetite has been poor and he has had trouble adhering to the physical therapy program. He has a history of well- controlled hypertension for many years. His postoperative medications include acetaminophen/codeine, amlodipine, and low-molecular-weight heparin. On physical examination, he is alert and uncomfortable. His blood pressure is 126/70 mm Hg, pulse rate is 110 beats/min, and temperature is 99.8 F (37.7 C). His height is 69 in (175.3 cm), and weight is 197 lb (89.5 kg) (BMI = 29.1 kg/m 2 ). He has truncal obesity, but does not appear cushingoid. He has no hyperpigmentation. His thyroid gland is normal. Findings on chest and cardiac examinations are remarkable only for a rapid regular beat. His abdomen is soft, but there is some guarding to palpation in the left flank. He has no edema, and findings on neurologic examination are normal.

11 Which of the following laboratory profiles would you expect? Answer Sodium Potassium Cortisol ACTH Aldosterone A. 136 meq/l (136 mmol/l) 3.2 meq/l (3.2 mmol/l) 33 mg/dl (910.4 nmol/l) 128 pg/ml (28.2 pmol/l) 2.6 ng/dl (72.1 pmol/l) B. 126 meq/l (126 mmol/l) 5.2 meq/l (5.2 mmol/l) 0.9 mg/dl (24.8 nmol/l) 456 pg/ml (100.3 pmol/l) 2.6 ng/dl (72.1 pmol/l) C. 146 meq/l (146 mmol/l) 4.6 meq/l (4.6 mmol/l) 2.8 mg/dl (77.2 nmol/l) 14 pg/ml (3.1 pmol/l) 12 ng/dl (332.9 pmol/l) D. 139 meq/l (139 mmol/l) 3.8 meq/l (3.8 mmol/l) 46 mg/dl ( nmol/l) 19 pg/ml (4.2 pmol/l) 2.8 ng/dl (77.7 pmol/l) E. 126 meq/l (126 mmol/l) 4.1 meq/l (4.1 mmol/l) 0.9 mg/dl (24.8 nmol/l) <5 pg/ml (1.1 pmol/l) 12 ng/dl (332.9 pmol/l) A. A B. B C. C D. D E. E 19) A 32-year-old man presents with hip pain and the radiographic findings shown (see image).

12 Serum calcium = 8.2 mg/dl ( mg/dl) (SI: 2.1 mmol/l [ mmol/l]) Phosphate = 2.2 mg/dl ( mg/dl) (SI: 0.7 mmol/l [ mmol/l]) Creatinine = 0.9 mg/dl ( mg/dl) (SI: 79.6 µmol/l [ µmol/l]) Serum alkaline phosphatase = 346 U/L ( U/L) (SI: 5.78 µkat/l [ 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 20) A 25-year-old woman presents for further evaluation and management of a left-sided thyroid nodule that was palpated by her gynecologist during a visit for an annual examination. The gynecologist had ordered thyroid function testing and thyroid ultrasonography and referred her to you. The patient has no history of thyroid dysfunction, no symptoms suggestive of either hypothyroidism or hyperthyroidism, and no compressive symptoms. On visual inspection, you note that her thyroid gland is asymmetric, with the left lobe being larger than the right. You palpate a mobile, soft, 1-cm nodule within the left lobe of the thyroid. Otherwise, she has no abnormal examination findings. Thyroid function test results: TSH = 1.2 miu/l ( miu/l) Free T 4 = 1.3 ng/dl ( ng/dl) (SI: 16.7 pmol/l [ pmol/l]) You review her ultrasound, which shows the 1-cm nodule palpated on the left side of her thyroid (see image, blue arrow) and a 1.2-cm, nonpalpable nodule in the contralateral lobe (see image, white arrow). Left lobe.

13 Right lobe. Which of the following is the best next diagnostic step? A. FNAB of the 1-cm nodule (in the left lobe) B. FNAB of the 1.2-cm nodule (in the right lobe) C. FNAB of both the 1-cm and 1.2-cm nodules D. Follow-up ultrasonography in 6 months 21) A 19-year-old man is referred to you for further treatment of gigantism that was diagnosed 3 months ago. His initial workup was prompted by a physical examination done for his college basketball team. During this examination, it was documented that he had grown one-half inch in the preceding 6 months and that he had noticed changes in the features of his face, hands, and feet that were suggestive of acromegaly. Laboratory test results were consistent with acromegaly (see table). A 2-cm sellar/suprasellar pituitary macroadenoma was documented on MRI. The patient underwent transsphenoidal resection of the tumor. The surgeon considered the resection to be complete. Now, 2 months after the operation, MRI shows postoperative changes, but no visible tumor mass. Other pituitary function is normal, including a testosterone measurement. A hand x-ray shows fused epiphyses. Findings on cardiac echocardiogram are normal. 1 Month 2 Months Measurement Preoperatively Postoperatively Postoperatively GH 28 ng/ml (28 µg/l) 0.8 ng/ml (0.8 µg/l) 0.5 ng/ml (0.5 µg/l) 1300 ng/ml ( ng/ml ( ng/ml (76.9 IGF-1* nmol/l) nmol/l) nmol/l) Prolactin 28 ng/ml (1.2 nmol/l) 10 ng/ml (0.4 nmol/l) *IGF-1 reference range for age: ng/ml (SI: nmol/l) When you evaluate the patient today, he feels well. His mother reports thinning of his face and hands since his operation. On physical examination, his height is 82.5 in (209.6 cm) and weight is 267 lb (121.4 kg) (BMI = 27.6 kg/m 2 ). Blood pressure is 110/76 mm Hg, and pulse rate is 64 beats/min. He has a slightly prominent lower jaw and large, but not full, hands and feet. Which of the following should you advise now?

14 A. Long-acting somatostatin analogue B. Pegvisomant C. Gamma-knife radiotherapy D. Cabergoline E. No additional therapy now 22) A 19-year-old Italian woman presents with hirsutism and irregular menses. She had early development of pubic hair at age 7 years. Menarche was at age 11 years. Her cycles have always been irregular, and she has been treated intermittently with oral contraceptives. On physical examination, her BMI is 25 kg/m 2. She has hair on her chin, upper lip, and neck; 8 hairs on her areolae; and hair to her umbilicus. She has no clitoromegaly. There is no facial plethora or violaceous striae. Findings on neuromuscular examination are normal. Laboratory test results (day 5 of an induced menstrual cycle): LH = 5.0 miu/ml ( miu/ml [follicular phase]) (SI: 5.0 IU/L [ IU/L]) FSH = 4.0 miu/ml ( miu/ml [follicular phase]) (SI: 4.0 IU/L [ IU/L]) Estradiol = 40 pg/ml ( pg/ml [follicular phase]) (SI: pmol/l [ pmol/l]) Testosterone = 50 ng/dl (8-60 ng/dl) (SI: 1.74 nmol/l [ nmol/l]) 17-Hydroxyprogesterone = 330 ng/dl (<285 ng/dl [luteal phase]; <80 ng/dl [follicular phase]) (SI: 10.0 nmol/l [<8.6 nmol/l] [luteal phase]; [<2.4 nmol/l] [follicular phase]) DHEA-S = 440 µg/dl ( µg/dl) (SI: 11.9 µmol/l [ µmol/l]) Prolactin = 18 ng/ml (4-30 ng/dl) (SI: 0.78 nmol/l [ nmol/l]) Which of the following is the best next step? A. 1-mg overnight dexamethasone suppression test C. Adrenal CT D. Transvaginal ultrasonography E. Measurement of 17-hydroxyprogesterone 30 minutes after cosyntropin 23) A 63-year-old man is evaluated in the diabetes clinic. His chief concern is muscle pain in the thighs and legs. The pain started in the right thigh but has progressed to both lower extremities over the last 3 months. He has had aching, burning pain, predominantly in the thighs. He has trouble getting out of bed and walking up stairs. His appetite is poor and he has lost 23 lb (10.5 kg) since symptoms began. Diabetes mellitus was diagnosed at age 56 years, and he takes metformin, 850 mg twice daily. He has a history of microalbuminuria and peripheral neuropathy, but he has never had a foot ulcer. He has hypertension and dyslipidemia for which he takes enalapril, 10 mg twice daily, and pravastatin, 40 mg daily. On physical examination, his height is 70 in (178 cm) and weight is 178 lb (80.9 kg) (BMI = 25.5 k/m 2 ). His blood pressure is 142/84 mm Hg, pulse rate is 86 beats/min, and respiratory rate is 12 breaths/min. Findings on examination of the heart, lungs, and abdomen are normal. There is wasting of the right quadriceps and decreased muscle strength with hip and knee flexion and extension and to a lesser degree in the ankles. Neurologic examination reveals absent ankle reflexes, diminished vibrational sense, and diminished response to monofilament testing in both feet. Hemoglobin A 1c = 8.0% (4.0%-5.6%) (64 mmol/mol [20-38 mmol/mol]) Creatinine = 1.3 mg/dl ( mg/dl) (SI: µmol/l [ µmol/l]) Estimated glomerular filtration rate = 60 ml/min per 1.73 m 2 (>60 ml/min per 1.73 m 2 ) Electrolytes, normal TSH, normal

15 Vitamin B 12 and folic acid, normal Creatine kinase, normal Serum electrophoresis, no monoclonal protein Erythrocyte sedimentation rate = 24 mm/h (0-20 mm/h) Which of the following is the best next step in this patient s management? A. Add insulin B. Add gabapentin C. Add prednisone D. Add pregabalin E. Stop metformin and start insulin 24) A 55-year-old woman presents with episodic palpitations, sweats, and headaches. Biochemical testing reveals that her plasma normetanephrine level is 5-fold greater than the upper limit of the reference range. Abdominal CT identifies a 3-cm left adrenal mass with a lipid-poor density of 34 Hounsfield units and a malignant-appearing, 2.5-cm right renal mass suggestive of renal cell carcinoma. Relevant family history includes a gastrointestinal stromal tumor in her 48- year- old brother and metastatic pheochromocytoma in her 58-year-old sister. Which of the following genes is most likely to harbor a pathogenic mutation in this patient? A. SDHB B. RET C. SDHAF2 D. MEN1 E. NF1 25) A 36-year-old woman with a peak lifetime BMI of 46 kg/m 2 had a laparoscopic gastric bypass operation in another state 8 weeks ago. She initially did well, but 3 weeks ago she started to have episodes of vomiting. Over the last 5 days, she has been vomiting almost everything she eats, and in the last 2 days, her husband says that she has become increasingly confused, dysarthric, and unsteady. 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 B 12 B. Vitamin D (severe) C. Thiamine D. Folate E. Zinc

16 26) A 39-year-old woman presents with a new 10-lb (4.5-kg) weight gain, constipation, irregular menses, and cold intolerance. She gets up very early in the morning for her job as a school bus driver and reports that she is exhausted by early afternoon. She has been feeling so poorly that she has called in sick to work for the past 4 days. Laboratory test results (sample collected while fasting): TSH = 167 miu/l ( miu/l) Free T 4 = 0.2 ng/dl ( ng/dl) (SI: 2.6 pmol/l [ pmol/l]) TPO antibodies = 692 IU/mL (<2.0 IU/mL) (SI: 692 kiu/l [<2.0 kiu/l]) LDL cholesterol = 201 mg/dl (<100 mg/dl [optimal]) (SI: 5.21 mmol/l [<2.59 mmol/l]) Total cholesterol = 292 mg/dl (<200 mg/dl [optimal]) (SI: 7.56 mmol/l [<5.18 mmol/l]) Triglycerides = 195 mg/dl (<150 mg/dl [optimal]) (SI: 2.20 mmol/l [<3.88 mmol/l]) HDL cholesterol = 52 mg/dl (>60 mg/dl [optimal]) (SI: 1.35 mmol/l [>1.55 mmol/l]) Levothyroxine is started. Which of the following is appropriate advice at the time of diagnosis? A. She can expect significant loss of fat mass within the next few months B. She should start a statin now to reduce the cardiovascular risk from her hypothyroidism C. It is safe to return to driving as soon as the levothyroxine is started D. She should use reliable contraception for the next few months 27) A 35-year-old woman has been evaluated on multiple occasions for frequent symptoms of tachycardia, sweating, tremor, and anxiety that are relieved by food intake. The spells are disruptive and have become noticeable over the past 6 months, but she has not required any assistance during these episodes. Recently, at the time of a routine blood draw and after a 14-hour fast, the patient was found to have a venous glucose concentration of 48 mg/dl (2.7 mmol/l). She is referred to you for evaluation. The patient has no notable medical history and is not taking any medication. She has never had surgery. She exercises regularly, and over the past 2 years she has participated in 4 halfmarathons. On physical examination, her resting heart rate is 45 beats/min and blood pressure is 105/60 mm Hg. Her height is 63 in (160 cm), and weight is 118 lb (53.6 kg) (BMI = 20.9 kg/m2). There has been no change in weight over the past year. An outpatient fast is undertaken. The patient last ate at 6:00 PM the preceding day and presents to the endocrine testing center at 8:00 AM. Symptoms occur at 9:45 AM. A point-of-care glucose value is 49 mg/dl (2.7 mmol/l). Blood is drawn for a hypoglycemia survey and glucagon is administered, with blood sampling every 10 minutes for the subsequent 30 minutes. The patient s glucose concentration is 52 mg/dl (2.9 mmol/l). Imaging studies of the pancreas would be indicated on the basis of which of the following sets of laboratory values?

17 Answer Insulin C-Peptide Proinsulin Glucose Rise after Glucagon (D) Insulin Antibodies Sulfonylurea Screen A. 3.2mIU/mL (22.2 pmol/l) 4.0 ng/ml (1.3 nmol/l) 16 pg/ml (1.8 pmol/l) 31 mg/dl (1.7 mmol/l) Negative Negative B. 15.0mIU/mL (101.2 pmol/l) 4.5 ng/ml (1.5 nmol/l) 32 pg/ml (3.6 pmol/l) 31 mg/dl (1.7 mmol/l) Negative Positive C mIU/mL (777.8 pmol/l) <2.0 ng/ml (<0.7 nmol/l) <5 pg/ml (<0.6 pmol/l) 38 mg/dl (2.1 mmol/l) Negative Negative D mIU/mL ( mmol/l) 10.3 ng/ml (3.4 nmol/l) 230 pg/ml (26.1 pmol/l) 45 mg/dl (2.5 mmol/l) Positive Negative E. 5.0mIU/mL (34.7 pmol/l) <2.0 ng/ml (0.7 nmol/l) <5 pg/ml (<0.6 pmol/l) 5 mg/dl (0.3 mmol/l) Negative Negative A. A B. B C. C D. D E. E 28) A 43-year-old woman with a history of hypertension and gastroesophageal reflux disease returns to see you 1 year after sleeve gastrectomy. You initially met her 2 years ago for evaluation and management of her medically complicated obesity. After a complete evaluation, you recommended she undergo bariatric surgery. The patient was reluctant to have Roux-en-Y gastric bypass because her sister had multiple complications after the same procedure. The patient instead elected to have a sleeve gastrectomy, and her BMI decreased from 44 to 28 kg/m 2. The patient is pleased with her weight loss, but reports dysphagia with solids and epigastric pain. Also, she frequently feels nauseated and has had 1 episode of vomiting. On physical examination, her vital signs are stable, abdomen is soft, bowel sounds are present, and there is no focal tenderness. Given her symptoms, which of the following should be performed next? A. Esophageal ph testing B. Upper gastrointestinal series C. Abdominal ultrasonography D. Abdominal CT

18 E. Gastric emptying study 29) A 24-year-old man with type 1 diabetes mellitus presents with fatigue and abdominal discomfort. Serum TSH = 15.2 miu/l ( miu/l) Free T 4 = 0.7 ng/dl ( ng/dl) (SI: 9.0 pmol/l [ pmol/l]) TPO antibodies, positive Replacement therapy with levothyroxine is initiated, but 2 weeks later he reports feeling worse than ever. On physical examination, the patient s blood pressure is 106/74 mm Hg and pulse rate is 104 beats/min. Repeated thyroid function testing: Serum TSH = 5.8 miu/l Free T 4 = 1.2 ng/dl (SI: 15.4 pmol/l) Which of the following is the most appropriate action now? A. Increase the levothyroxine dosage B. Measure serum vitamin B 12 levels C. Assess transglutaminase antibody titers D. Evaluate for autonomic insufficiency E. Evaluate for adrenal insufficiency 30) A 37-year-old woman presents for ongoing management of hyperthyroidism. Graves disease was diagnosed 3 months ago when she presented with typical symptoms and signs of thyrotoxicosis. She did not report any symptoms of ophthalmopathy and there was no clinical evidence of thyroid eye disease at presentation. Laboratory test results at diagnosis: Serum TSH = <0.01 miu/l ( miu/l) Serum free T 4 = 3.5 ng/dl ( ng/dl) (SI: 45.0 pmol/l [ pmol/l]) Serum free T 3 = 9.8 pg/ml ( pg/ml) (SI: 15.1 pmol/l [ pmol/l]) TSH receptor antibodies, markedly elevated She smokes 10 cigarettes daily (she started smoking at age 18 years). Her primary care physician prescribed methimazole, 20 mg daily, and propranolol, 80 mg twice daily. Although she initially felt better after starting methimazole and propranolol, she reports nausea within 2 hours of taking methimazole and increasing joint pains and itchy skin in the past 2 months. Moreover, she has developed progressive redness and watering of her eyes over the past 4 weeks. Acquaintances have commented that her eyes are bulging, but she does not have any vision disturbance. On eye examination, she has bilateral lid retraction (<2 mm) and proptosis (1 mm of the left eye and 2 mm of the right eye). There is bilateral conjunctival injection and bilateral swelling and redness of the eyelids. Visual acuity is 6/6 bilaterally, and there is no restriction of eye movements. On physical examination, a diffuse, smooth goiter is palpable in her neck. She does not have a rash. Laboratory test results today: Serum TSH = <0.01 miu/l Serum free T 4 = 2.6 ng/dl (SI: 33.5 pmol/l) Serum free T 3 = 5.9 pg/ml (SI: 9.1 pmol/l) The patient reports that her sister was successfully treated with radioactive iodine for Graves disease 5 years earlier and she would like to undergo the same therapy. In addition to smoking cessation, which of the following should you recommend for the subsequent management of

19 her thyrotoxicosis? A. Replace methimazole with propylthiouracil B. Administer radioiodine with concurrent corticosteroid treatment C. Continue methimazole with concurrent corticosteroid treatment D. Proceed with total thyroidectomy E. Continue current regimen 31) You are called to the surgical intensive care unit to evaluate a 21-year-old man admitted 48 hours ago after head trauma caused by a motor vehicle crash. The patient has no notable medical history. Head CT is normal, but he is unresponsive and intubated. The intensive care unit team has had problems maintaining his blood pressure, and the diagnosis of adrenal insufficiency is being considered. He is presently on an epinephrine drip. Physical examination findings are normal except for vital signs. His blood pressure is 85/60 mm Hg, and pulse rate is 112 beats/min. Testes are normal size. Sodium = 137 meq/l ( meq/l) (SI: 137 mmol/l [ mmol/l]) Potassium = 4.0 meq/l ( meq/l) (SI: 4.0 mmol/l [ mmol/l]) Serum urea nitrogen = 21 mg/dl (8-23 mg/dl) (SI: 7.5 mmol/l [ mmol/l]) Creatinine = 1.1 mg/dl ( mg/dl) (SI: 97.2 µmol/l [ µmol/l]) The intensive care unit team has just performed a 250-mcg ACTH simulation test. The baseline cortisol value was 3.9 µg/dl (107.6 nmol/l). Sixty minutes after administration of 250 mcg of ACTH, it was 24.1 µg/dl (664.9 nmol/l). Which of the following is the most appropriate next step? A. Measureserumaldosterone B. Perform another ACTH stimulation test with 1 mcg of C. ACTH Administer fludrocortisone D. Administer stress-dose steroids E. No other testing required 32) A new drug acting by which of the following mechanisms would be predicted to be an effective weight-loss medication? A. Agouti-related protein (AGRP) receptor agonist B. Neuropeptide Y (NPY) receptor agonist C. Melanocortin 4 receptor (MC4R) agonist D. Ghrelin receptor agonist E. Glucagonlike protein 1 (GLP-1) receptor antagonist 33) A 26-year-old woman with a 13-year history of type 1 diabetes mellitus and β-thalassemia requests help with her diabetes management. Despite being on a basal-bolus regimen with insulin glargine and insulin aspart for 5 years and checking her blood glucose 5 to 7 times daily with appropriate insulin adjustments, she has been unable to reduce her hemoglobin A 1c level below 8.0% (<64 mmol/mol). This is mainly because she has had frequent mild hypoglycemia with any increases in her insulin dosage, mostly during daylight hours. Her weight is 122 lb (55.5 kg), and her hemoglobin A1c level is 8.2% (66 mmol/mol). Her serum creatinine level and urinary albumin-to-creatinine ratio are normal. You confirm the accuracy of her meter readings by comparison with a laboratory glucose test result. Review of her glucose meter for the last 30 days shows 181 values, which are averaged in the Table:

20 Morning Lunch Dinner Bedtime Overnight Overall Mean glucose 136 mg/dl (±20) (7.6 mmol/l [±1.1]) 142 mg/dl (±34) (7.9 mmol/l [±1.9]) 133 mg/dl (±27) (7.4 mmol/l [±1.5]) 132 mg/dl (±31) (7.3 mmol/l [±2.3]) 96 mg/dl (±19) (5.3 mmol/l [±1.1]) 128 mg/dl (±21) (7.1 mmol/l [±1.2]) Values are presented with standard deviation in parentheses. Which of the following is the best management option now? A. Use self-monitored glucose levels to guide treatment B. Increase insulin glargine by 2 units every 3 days to keep fasting blood glucose levels between 80 and 130 mg/dl (4.4 and 7.2 mmol/l) C. Add a twice-daily glucagonlike peptide 1 receptor agonist before breakfast and her evening meal D. Adjust the insulin-to-carbohydrate ratio E. Initiate insulin pump therapy 34) A 33-year-old man is evaluated for low libido and erectile dysfunction of 5 months duration. He also notes loss of morning erections over the same time frame. There is no history of head or testicular trauma. He is married and has fathered 2 children. His medical history is notable for rheumatoid arthritis diagnosed 9 months ago. He was prescribed methotrexate, 7.5 mg weekly, and prednisone, 60 mg daily. Three months ago, his prednisone dosage was reduced to 20 mg daily because his arthritic symptoms were markedly improved. He takes no other medications. On physical examination, the patient has a round face with mild plethora. BMI is 28.1 kg/m 2. His visual fields are normal. Testicular volume is 15 ml bilaterally. He has mild swelling of the distal interphalangeal joints. Total testosterone (morning) = 151 ng/dl ( ng/dl) (SI: 5.2 nmol/l nmol/l]) LH = 2.9 miu/ml ( miu/ml) (SI: 2.9 IU/L [ IU/L]) FSH = 3.3 miu/ml ( miu/ml) (SI: 3.3 IU/L [ IU/L]) Prolactin = 13 ng/ml (4-23 ng/ml) (SI: 0.6 nmol/l [ nmol/l]) Transferrin saturation = 32% (14%-50%) Pituitary MRI shows a 3-mm microadenoma without evidence of stalk deviation. Which of the following is most likely to be responsible for the patient's androgen deficiency? A. Pituitary adenoma B. Methotrexate C. Prednisone D. Hemochromatosis 35) A 31-year-old woman first presented 4 years earlier with amenorrhea and galactorrhea. An 11-mm prolactinoma was identified, and she has since been treated with cabergoline. Her current dosage is 0.5 mg twice weekly. She has regular menses and no galactorrhea. She has recently married and wishes to become pregnant as soon as possible; she is using no contraception. On physical examination, she appears well. Her height is 64 in (162.6 cm), and weight is 140 lb (63.6 kg) (BMI = 24 kg/m2). Her blood pressure is 105/68 mm Hg. No abnormalities are noted.

21 Prolactin = 26 ng/ml (4-30 ng/ml) (SI: 1.13 nmol/l [ nmol/l]) β-hcg = 2.1 miu/ml (<3.0 miu/ml) (SI: 2.1 miu/ml [<3.0 IU/L]) Pituitary MRI shows a 5-mm left-sided microadenoma (see image, arrow). Which of the following is the best advice for this patient? A.Stop cabergoline now B.Stop cabergoline once pregnant C. Switch from cabergoline to bromocriptine once pregnant D.Reducethecabergolinedosageto0.25mgonceweekly E.Continue cabergoline indefinitely 36) A 27-year-old woman is referred to your office for hirsutism, amenorrhea, and an elevated 17- hydroxyprogesterone level. She notes irregular menses starting at menarche, with cycles every 45 to 60 days. Her last menses was 2 months ago. She reports hirsutism on her chin, lower abdomen, and upper thighs since age 18 years. She had been taking an oral contraceptive for 8 years, but stopped 5 months ago to try for pregnancy. Her hirsutism has worsened since stopping hormonal contraception. Her physical examination is notable for mild hirsutism with a Ferriman-Gallwey score of 10. Laboratory test results from 1 month ago: Total testosterone = 69 ng/dl (8-60 ng/dl) (SI: 2.4 nmol/l [ nmol/l]) DHEA-S = 115 µg/dl ( µg/dl) (SI: 3.1 µmol/l [ µmol/l]) 17-Hydroxyprogesterone = 687 ng/dl (<80 ng/dl [follicular]) (SI: 20.8 nmol/l [<2.4 nmol/l]) Progesterone = 23.5 ng/ml ( 1.0 ng/ml [follicular]) (SI: 74.7 nmol/l [ 3.2 nmol/l]) Estradiol = 1970 pg/ml ( pg/ml [follicular]) (SI: 7232 pmol/l [ pmol/l]) Which of the following is the best next step in the evaluation of this patient? A. ACTH stimulation test B. CT of the adrenal glands C. Ovarian ultrasonography D. Free testosterone measurement E. hcg measurement 37) A 21-year-old woman comes to your practice for the first time on transfer of care from her pediatric

22 endocrinologist. Congenital adrenal hyperplasia due to 21-hydoxylase deficiency was diagnosed at birth. Her current treatment consists of dexamethasone, 0.5 mg at bedtime, and fludrocortisone acetate, 0.1 mg every morning. She has regular menses, is not sexually active, and is not attempting to become pregnant. Her only concerns are difficulty losing weight and poor sleep. On physical examination, her height is 58 in (147.3 cm) and weight is 143 lb (65 kg) (BMI = 29.9 kg/m 2 ). Her blood pressure is 110/66 mm Hg. She has no hirsutism, acne, or purple striae, and her skin is somewhat thinned. Sodium = 138 meq/l ( meq/l) (SI: 138 mmol/l [ mmol/l]) Potassium = 4.8 meq/l ( meq/l) (SI: 4.8 mmol/l [ mmol/l]) Serum DHEA-S = = <15 µg/dl ( µg/dl) (SI: <0.4 µmol/l [ µmol/l]) Serum testosterone = <20 ng/dl (8-60 ng/dl) (SI: <0.7 nmol/l [ nmol/l]) Plasma renin activity = 3.4 ng/ml per h ( ng/ml per h) Serum androstenedione = 30 ng/dl ( ng/dl) (SI: 1.0 nmol/l [ nmol/l]) Which of the following is the most appropriate next step in her management? A. Order genotyping of the CYP21A2 gene B. Measure serum 17-hydroxyprogesterone C. Divide the dexamethasone dose as 0.25 mg twice daily D. Reduce the glucocorticoid dosage E. Stop fludrocortisone acetate 38) A 68-year-old man is admitted to the hospital for worsening back pain and obstructive urinary symptoms. His only home medication is hydrochlorothiazide, 50 mg daily. CT shows a large necrotic prostate mass with metastases to the pelvis and spine. Laboratory test results reveal a calcium concentration of 15.1 mg/dl ( mg/dl) (SI: 3.8 mmol/l [ mmol/l]), and he is given 4 mg of intravenous zoledronic acid. Additionally, high-dosage dexamethasone is initiated for spinal cord compromise, and high-dosage ketoconazole is initiated for rapid medical castration. You are now consulted for symptomatic hypocalcemia that has been present for 4 days since his admission despite frequent infusions of calcium gluconate, 1 g intravenously. When you tap the skin over his facial nerve, contractions are seen. His reflexes are brisk. Serum total calcium = 5.6 mg/dl ( mg/dl) (SI: 1.4 mmol/l [ mmol/l]) Ionized calcium = 2.9 mg/dl ( mg/dl) (SI: 0.7 mmol/l [ mmol/l]) Phosphate = 1.7 mg/dl ( mg/dl) (SI: 0.5 mmol/l [ mmol/l]) Serum creatinine = 1.3 mg/dl ( mg/dl) (SI: µmol/l [ µmol/l]) Alkaline phosphatase = 81 U/L ( U/L) (SI: 1.35 µkat/l [ µkat/l]) PTH = 245 pg/ml (10-65 pg/ml) (SI: 245 ng/l [10-65 ng/l]) PTHrP = 34.9 pg/ml (14-27 pg/ml) (SI: 34.9 ng/l [14-27 ng/l]) Magnesium = 2.0 mg/dl ( mg/dl) (SI: 0.8 mmol/l [ mmol/l]) Albumin = 2.9 g/dl ( g/dl) (SI: 29 g/l [35-50 g/l]) 25-Hydroxyvitamin D = <8 ng/ml (25-80 ng/ml [optimal]) (SI: <20.0 nmol/l [ nmol/l]) In addition to this patient s vitamin D deficiency, which other factor had a role in his severe hypocalcemia after bisphosphonate infusion? A. Ketoconazole B. Osteolytic metastases C. Adrenal insufficiency D. Thiazide diuretic use

23 39) You are asked to see a 40-year-old hospitalized man for evaluation of bilateral gynecomastia. The patient was in good health until 6 weeks ago when he developed mild intermittent hemoptysis. Worsening hemoptysis brought him to the emergency department 2 days ago. Chest roentgenogram is grossly abnormal (see images). Posteroanterior view. Lateral view. The patient has been admitted to the hospital for the workup of hemoptysis. Bilateral gynecomastia was noted on initial physical examination, which prompted a request for endocrine consultation. The patient reports first noticing breast enlargement 7 months ago; however, over the past 3 months, his breasts have increased in size and have become tender. He has no galactorrhea. He reluctantly shares that he has noticed an increase in his left testicular size. His libido has been normal. He has no hepatic disease; he does not consume alcohol. Review of systems is notable for palpitations and sweaty palms. He has no headache or vision symptoms. He is married and has 2 biologic children. On physical examination, he is a well-developed man. His blood pressure is 148/68 mm Hg, and pulse rate is 96 beats/min. BMI is 29 kg/m 2. He has normal facial and body hair. There is no proptosis, but bilateral lid retraction is present. His thyroid gland is normal. There is bilateral gynecomastia: 3.5 cm (left breast) and 3 cm (right breast). The breasts are tender without nipple discoloration or retraction. Auscultation of the lungs reveals decreased air entry at the bases. His phallus and scrotum are normal. The right testis is normal with a volume of 20 ml; the left testis is larger with a hard, irregular mass. Deep tendon reflexes are brisk. In addition to an elevated hcg level, which of the following patterns of hormonal abnormalities is likely to be present in this patient? A. A B. B C. C D. D

24 E. E 40) After passing a kidney stone, a generally healthy 20-year-old woman is referred to you by her urologist. She does not take any calcium or vitamin supplements. Serum calcium = 11.0 mg/dl ( mg/dl) (SI: 2.8 mmol/l [ mmol/l]) 25-Hydroxyvitamin D = 70 ng/ml (25-80 ng/ml [optimal]) (SI: nmol/l [ nmol/l]) 1,25-Dihydroxyvitamin D = 75 pg/ml (16-65 pg/ml) (SI: 195 pmol/l [ pmol/l]) PTH = <10 pg/ml (10-65 pg/ml) (SI: <10 ng/l [10-65 ng/l]) Serum protein electrophoresis and urine protein electrophoresis, normal PTHrP, undetectable A PET-CT is normal. Her brother also has nephrolithiasis. Measurement of which of the following would result in a definitive diagnosis? A. 24,25-Dihydroxyvitamin D B. 24-Hour urinary calcium C. Serum phosphate D. Serum C-telopeptide 41) 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 diabeticorum D. Necrolytic migratory erythema E. Granuloma annulare

25 42) A 59-year-old woman is referred to you for evaluation of hypophosphatemia. She had a liver transplant 10 years ago for alcoholic cirrhosis, after which she stopped drinking alcohol. She developed hepatitis B after the transplant. Osteoporosis was diagnosed 10 years ago and was treated with oral bisphosphonates for 5 years. Over the past 5 years, she has had severe, diffuse bone pain and has had fractures diagnosed at L3, the pelvis, and several ribs. A recent hip radiograph showed a medial stress fracture of the proximal femur. Medications include tacrolimus, mycophenolate, and tenofovir. DXA shows T scores of 4.4 in the spine and 3.2 in the total hip. Alanine aminotransferase, normal Aspartate aminotransferase, normal Complete blood count, normal Alkaline phosphatase = 412 U/L ( U/L) (SI: 6.88 kat/l [ kat/l]) 25-Hydroxyvitamin D = 25 ng/ml (25-80 ng/ml [optimal]) (SI: 62.4 nmol/l [ nmol/l]) 1,25-Dihydroxyvitamin D = 52.6 pg/ml (16-65 pg/ml) (SI: pmol/l [ pmol/l]) PTH = 65 pg/ml (10-65 pg/ml) (SI: 65 ng/l [10-65 ng/l]) Creatinine = 0.9 mg/dl ( mg/dl) (SI: 79.6 mol/l [ mol/l]) Calcium = 8.9 mg/dl ( mg/dl) (SI: 2.2 mmol/l [ mmol/l]) Phosphate = 1.2 mg/dl ( mg/dl) (SI: 0.4 mmol/l [ mmol/l]) Fibroblast growth factor 23 = 150 RU/mL (<180 RU/mL) Urinalysis dipstick, normal Tubular reabsorption of phosphate (TRP) = 80% (>95%) Which of the following would be most likely to correct her hypophosphatemia? A. Change from tenofovir to entecavir B. Change from tacrolimus to prednisone C. Start octreotide D. Add calcitriol 43) A 28-year-old woman with polycystic ovary syndrome presents to your office to discuss the health risks associated with her diagnosis. She had early menarche at age 11 years, hirsutism and acne since age 13 years, and weight gain from 120 lb (54.5 kg) to 170 lb (77.3 kg) in her 20s. She has a family history of hypertension and type 2 diabetes mellitus. She has been trying to lose weight on a low-carbohydrate diet, and she started an exercise program to improve her chance of fertility. Physical examination reveals normal vital signs and mild hirsutism and without signs of hypercortisolism. Findings on cardiovascular and pulmonary examinations are normal. For which of the following is she at increased risk as compared with the general population? A. Autoimmune thyroid disease B. Stroke C. Myocardial infarction D. Obstructive sleep apnea E. Development of pituitary tumor 44) A 38-year-old man with a 25-year history of type 1 diabetes mellitus has a history of a healed right plantar ulcer 2 years ago. His hemoglobin A 1c level is 7.6% (60 mmol/mol) on multiple daily insulin injections. He has hypertension controlled on an ACE inhibitor and dyslipidemia controlled on a statin. On foot examination, he has absent sensation to 10-g monofilament, absent ankle reflexes, callus formation on the plantar aspect of the second and third metatarsal heads, and diminished pedal pulses.

26 Which of the following is the strongest predictor of the development of future foot ulcers in this patient? A. Absent ankle reflexes B. Peripheral vascular disease C. Abnormal monofilament testing D. Male gender E. History of previous ulceration 45) You are asked to evaluate a 56-year-old woman with an adrenal mass. Breast cancer (T2 N1 M0) was diagnosed 1 year ago and she is currently on letrozole therapy. She has no other notable health problems and takes no other medications. On physical examination, she appears well. Her blood pressure is 112/78 mm Hg. Her height is 65 in (165 cm), and weight is 135 lb (61.4 kg) (BMI = 22.5 kg/m 2 ). No abnormalities are noted. Cortisol (8 AM, after 1 mg overnight dexamethasone suppression test) = 1.1 μg/dl (SI: 30.3 nmol/l) Metanephrines (plasma fractionated) o Metanephrine = 22 pg/ml (<57 pg/ml) (SI: pmol/l [<289 pmol/l]) o Normetanephrine = 112 pg/ml (<148 pg/ml) (SI: pmol/l [<808 pmol/l]) Aldosterone = 10 ng/dl (1-21 ng/dl) (SI: pmol/l [ pmol/l]) Plasma renin activity = 1.4 ng/ml per h ( ng/ml per h) CT of adrenal glands is shown (see noncontrast image). The CT is interpreted as showing a 2.7-cm adrenal adenoma (arrow) with a density of 10 Hounsfield units and greater than 50% washout 10 minutes after contrast. Which of the following is the best step in the management of this patient s adrenal mass? A.No immediate further evaluation B. Adrenal biopsy C. Laparoscopic adrenalectomy D. Fluorodeoxyglucose PET CT E. Adrenal MRI

27 46) A 43-year-old woman is referred for management of Cushing disease manifested by typical signs and symptoms. Urinary free cortisol = 451 µg/24 h (4-50 µg/24 h) (SI: nmol/d [ nmol/d]) Serum cortisol (8 AM) = 28 µg/dl (5-25 µg/dl) (SI: nmol/l [ nmol/l]) ACTH = 93 pg/ml (10-60 pg/ml) (SI: 20.5 pmol/l [ pmol/l]) Following incomplete surgical removal of her 9-mm pituitary adenoma, her hormone levels remain elevated. While on medical therapy, the patient subsequently develops diabetes mellitus. Which of the following treatment options is most likely to be contributing to the development of diabetes in this patient? A. Metyrapone B. Pasireotide C. Ketoconazole D. Mifepristone 47) A nephrologist colleague asks you for an opinion regarding a 42-year-old woman with primary hyperaldosteronism diagnosed 2 months earlier. Her blood pressure has been well controlled on spironolactone alone, and her other antihypertensive medications have been discontinued. She has a normal potassium concentration without supplementation. She had initially presented with a 6-year history of intermittent hypokalemia and hypertension requiring 3 to 4 antihypertensive medications. Initial laboratory test results (while taking lisinopril, hydrochlorothiazide, and amlodipine): Morning serum aldosterone = 19 ng/dl (1-21 ng/dl) (SI: pmol/l [ pmol/l]) Plasma renin activity = 0.2 ng/ml per h ( ng/ml per h) Urinary aldosterone = 18 µg/24 h Urinary sodium = 202 meq/24 h ( meq/24 h) (SI: 202 mmol/d [ mmol/d]) Abdominal CT showed normal adrenal glands. Bilateral adrenal venous sampling without ACTH stimulation demonstrated the following: Measurement Right Adrenal Vein Left Adrenal Vein Inferior Vena Cava Aldosterone 438 ng/dl (12,150 pmol/l) 198 ng/dl (5493 pmol/l) 21 ng/dl (583 pmol/l) Cortisol 101 µg/dl (2786 nmol/l) 62 µg/dl (1711 nmol/l) 20 µg/dl (552 nmol/l) Aldosterone-to-cortisol ratio Epinephrine 9783 pg/ml 766 pg/ml <10 pg/ml

28 (53,356 pmol/l) (4178 pmol/l) (<55 pmol/l) Which of the following should you recommend? A. Substitution of eplerenone for spironolactone at the same dosage B. Laparoscopic right adrenalectomy C. Another adrenal venous sampling procedure with ACTH stimulation D. Magnetic resonance angiography of the renal arteries E. No change incurrent treatment 48) A 19-year-old man is referred for gigantism. His height is 82 in (208.3 cm), and his weight is 273 lb (124.1 kg) (BMI =28.5 kg/m 2 ), His hands and feet are enlarged, and he has prognathism. A maternal uncle was thought to have had a pituitary adenoma of uncertain type. There is no known family history of calcium disorders or kidney stones. Random GH = 90 ng/ml ( ng/ml) (SI: 90 µg/l [ µg/l]) Serum IGF-1 = 1233 ng/ml ( ng/ml) (SI: nmol/l [ nmol/l]) Serum calcium, normal MRI shows a 4.3-cm pituitary adenoma with suprasellar extension. A germline mutation in which of the following genes is most likely responsible for the findings in this patient? A. GNAS (GNAS complex locus) B. PROP1 (PROP paired-like homeobox 1) C. AIP (aryl hydrocarbon receptor interacting protein) D. MEN1 (menin) 49) A 30-year-old patient (46,XX karyotype) with gender dysphoria presents for follow-up after initiating hormone treatment. He had undergone psychological evaluation and lived as a male for the last 6 months before starting androgen therapy. He was treated with topical testosterone, 50 mg daily. He has never smoked cigarettes. He is now seen after 6 months for follow-up. He notes increased facial and body hair, deepening of his voice, and enlargement of the clitoris. He reports an improvement in strength and an increase in libido. On physical examination, his blood pressure is 132/70 mm Hg. His height is 66.5 in (168.9 cm), and weight is 197 lb (89.5 kg) (BMI = 31.3 kg/m 2 ). Skin examination reveals mild acne and increased male- pattern hair over the face, chest, and extremities with some temporal balding. Total testosterone = 711 ng/dl ( ng/dl [male]; 8-60 ng/dl [female]) (SI: 24.6 nmol/l [ nmol/l] [male]; [ nmol/l] [female]) Which of the following is the most likely metabolic change after starting testosterone treatment in this patient? A. Decreased visceral adiposity B. Increased body mass index D. Increased HDL cholesterol

29 E. Decreased waist-to-hip ratio 50) A 38-year-old man is referred to you for persistent hypercalcemia. He has no history of peptic ulcer disease, nephrolithiasis, or hypertension. Eight months ago, he underwent parathyroidectomy on the basis of the following laboratory values: Serum calcium = 11.5 mg/dl ( mg/dl) (SI: 2.88 mmol/l [ mmol/l]) PTH = 50 pg/ml (10-65 pg/ml) (SI: 50 ng/l [10-65 ng/l]) Serum creatinine = 1.05 mg/dl ( mg/dl) (SI: 92.8 mmol/l [ µmol/l]) 25-Hydroxyvitamin D = 22 ng/ml (25-80 ng/ml [optimal]) (SI: 54.9 nmol/l [ nmol/l]) Serum phosphate = 2.1 mg/dl ( mg/dl) (SI: 0.68 mmol/l [ mmol/l]) Two enlarged glands were resected during the operation, with the final pathology report documenting hyperplasia in both glands. However, intraoperative PTH levels remained elevated. Postoperatively, his calcium concentration was 11.6 mg/dl (2.90 mmol/l) and his PTH concentration was 54 pg/ml (54 ng/l). Which of the following is the best next step in his care? A. Perform neck ultrasonography B. Order a 4D CT of the neck C. Refer for a second surgery with biopsy and resection of 1 or both remaining parathyroid glands D. Measure 24-hour urinary calcium and creatinine excretion 51) A 62-year-old man with a history of type 2 diabetes mellitus complicated by nonproliferative retinopathy and microalbuminuria returns to see you for a follow-up appointment and management of his blood glucose levels. His diabetes was initially treated with oral antihyperglycemic medications; however, he required the addition of insulin to his regimen approximately 5 years ago. In addition to metformin, he currently takes 2 daily injections of 75% insulin lispro protamine suspension/25% insulin lispro injection (75/25 insulin) at the dose of 50 units before breakfast and 30 units before his evening meal. The patient reports consistently eating 3 meals per day, generally at 7:00 AM, 11:30 AM, and 7:00 PM. He reports good adherence to his medical therapy. He has expressed frustration over his hemoglobin A 1c values, as his fingerstick glucose levels checked twice daily before administration of his insulin doses are almost always 150 mg/dl (8.3 mmol/l) or lower. He has had no problems with hypoglycemia or hypoglycemia unawareness. His point-of-care hemoglobin A 1c level at today s visit is unchanged at 9.1% (76 mmol/mol). The patient has worn a continuous glucose monitor for 5 days before today s office visit. He reports no notable alteration in his medication use, dietary habits, or physical activity during this period. The data obtained from the continuous glucose monitor are displayed (see graph).

30 Which of the following is the best next step in this patient s care? A. Give the patient a new blood glucose testing meter B. Change to 45 units of once-daily basal, long-acting insulin and 15 units of rapid-acting insulin before meals C. Change timing of blood glucose testing to 2 hours after the start of each meal D. Modify 75/25 insulin dosing to 60 units before breakfast and 30 units before the evening meal E. Modify 75/25 insulin dosing to 50 units before breakfast and 40 units before the evening meal 52) A 72-year-old man is referred after the detection of a retrosternal goiter with tracheal deviation on a chest radiograph. The patient has a 6-month history of mild positional dyspnea at rest and intermittent orthopnea. He reports no symptoms of stridor, dysphagia, or dysphonia. He has a longstanding history of mild chronic obstructive pulmonary disease and is a former cigarette smoker. On physical examination, he has a multinodular goiter in the neck that is palpable in a neutral position and visible in a supine position with neck extension. The lower lobe of the thyroid gland extends below the sternal notch and cannot be palpated. The Pemberton sign is negative. There is tracheal deviation to the left. The rest of his examination findings are normal. Serum TSH = 3.5 miu/l ( miu/l) Serum free T 4 = 1.2 ng/dl ( ng/dl) (SI: 15.4 pmol/l [ pmol/l]) TPO antibodies = 18 IU/mL (<2.0 IU/mL) (SI: 18 kiu/l [<2.0 kiu/l] Pulmonary Function Test: Flow volume loop does not show evidence of clinically significant extrathoracic

31 Axial view. Coronal view. The patient s primary care physician has suggested that he will require surgery, but the patient would like to avoid surgery if possible. Which of the following treatment strategies should you recommend now? A. Prednisone, 40 mg daily for 2 weeks, then taper over 1 month B. Levothyroxine sufficient to suppress TSH below the lower limit of the reference range C. No therapy now; perform another CT in 4 to 6 months D. Total thyroidectomy E. Radioactive iodine ablation following administration of recombinant human TSH 53) A 36-year-old woman has a 10-year history of anxiety and depression. She has been treated with venlafaxine for 5 years with substantial improvements in her anxiety, but over the last year she has developed more frequent anxiety episodes and occasional palpitations. Alprazolam was prescribed several weeks ago, but it has not relieved her symptoms. During a routine primary care appointment, her blood pressure was 162/90 mm Hg, her pulse rate was 102 beats/min, and she was noted to be anxious. Her primary care physician ordered thyroid function tests, which were normal, and then ordered measurement of plasma metanephrines to evaluate whether she could have a catecholamine- producing tumor contributing to her anxiety. Plasma normetanephrine = 222 pg/ml (<148 pg/ml) (SI: pmol/l [<808 pmol/l]) Plasma metanephrine = 80 pg/ml (<57 pg/ml) (SI: pmol/l [<289 pmol/l])

32 Which of the following is the most likely interpretation of these results? A. Anxiety B. False-positive results related to venlafaxine use C. False-positive results related to alprazolam use D. Paraganglioma E. Pheochromocytoma 54) A 78-year-old man is seen by his primary care physician for his annual check-up. Generally, he feels well and has no specific concerns, except for a gradual decrease in his energy level and strength. His only chronic medical problems are hypertension and osteoarthritis. On physical examination, his weight is unchanged from 1 year ago and his BMI is normal. His blood pressure is 134/80 mm Hg. Palpation of the neck reveals a normal-sized, slightly firm thyroid gland. His examination findings are otherwise unremarkable aside from osteoarthritis in his hands. Serum sodium = 134 meq/l ( meq/l) (SI: 134 mmol/l [ mmol/l]) Other serum electrolytes, normal Total cholesterol = 180 mg/dl (<200 mg/dl [optimal]) (SI: 4.66 mmol/l [<5.18 mmol/l]) LDL cholesterol = 129 mg/dl (<100 mg/dl [optimal]) (SI: 3.34 mmol/l [<2.59 mmol/l]) TSH = 5.7 miu/l ( miu/l) Laboratory test results 2 months later: TSH = 5.9 miu/l ( miu/l) Free T 4 = 1.0 ng/dl ( ng/dl) (SI: 12.9 pmol/l [ pmol/l]) TPO antibodies = <2.0 IU/mL (<2.0 IU/mL) (SI: <2.0 kiu/l [<2.0 kiu/l]) In addition to explaining that his thyroid hormones should be monitored going forward, which of the following would you recommend now? A. Levothyroxine, 1.6 mcg/kg daily B. Levothyroxine, 25 mcg daily C. Levothyroxine initiation if his serum LDL-cholesterol concentration rises above 130 mg/dl (>3.37 mmol/l) D. Levothyroxine initiation if his serum sodium remains below the normal range during routine follow-up testing E. No thyroid hormone replacement 55) A 36-year-old pharmacist is referred for evaluation of a low serum testosterone level. He reports decreased libido, low energy, and hand arthralgias. He has a 16-year-old biologic son, but no children in his second marriage. He takes no medications and is generally healthy. Specifically, he does not take opioids, androgenic anabolic steroids, or corticosteroids. On physical examination, he is well virilized with normal secondary sexual characteristics and a BMI of 24 kg/m². He has normal skin without striae. There is no gynecomastia. Testicular volume is 15 ml bilaterally. The patient has a normal gait and is able to squat without using his arms to assist. Total testosterone = 150 ng/dl ( ng/dl) (SI: 5.2 nmol/l [ nmol/l]) Serum prolactin = 20 ng/ml (5-20 ng/ml) (SI: 0.9 nmol/l [ nmol/l]) FSH = 3.0 miu/ml ( miu/ml) (SI: 3.0 IU/L [ IU/L])

33 LH = 3.0 miu/ml ( miu/ml) (SI: 3.0 IU/L [ IU/L]) X-ray of the hands reveals chondrocalcinosis of the small joints bilaterally. Sellar MRI reveals no pituitary mass. Which of the following studies is most likely to identify this patient s diagnosis? A. Assessment of transferrin saturation B. Urine toxicology screen for opioids C. Serum epitestosterone measurement E. Measurement of serum prolactin after serial dilution 56) A 34-year-old Asian man with a history of Graves disease has developed episodes of diaphoresis, tachycardia, and tremor over the past 6 months. These episodes typically occur during prolonged fasting or during exercise and are reversed with ingestion of sugared beverages. He is brought to the emergency department after losing consciousness during a soccer match in which he was participating. His hyperthyroidism has been treated with methimazole, 20 mg daily, and his TSH levels have been normal over the past year. He has no other notable medical history. He has no family members with diabetes mellitus or hypoglycemia. On physical examination, he is lethargic and diaphoretic. His blood pressure is 148/92 mm Hg, and his pulse rate is 108 beats/min. Vitiligo is noted. His thyroid is nonpalpable. His lungs are clear, he is oxygenating well, and cardiac sounds are rapid but otherwise normal. His abdomen is soft without masses. Neurologic testing is otherwise nonfocal. The rest of the examination findings are unremarkable. A blood glucose measurement is documented to be 37 mg/dl (2.1 mmol/l). Results of other routine laboratory tests are normal, including those assessing renal and hepatic function. Although all of the following tests may appropriately be part of the evaluation for hypoglycemia, which test is most likely to demonstrate the cause of this patient s hypoglycemic syndrome? A. Insulin autoantibody assessment B. Urinary sulfonylurea screen C. Cortisol measurement D. Urinary ketone assessment 57) A 58-year-old woman with stage IV medullary thyroid cancer is referred for consideration of further therapy. Medullary thyroid cancer was diagnosed 8 years earlier and she had a persistent postoperative serum calcitonin elevation. Distant metastases to the lungs and ribs were detected 1 year ago, with disease progression over the past 6 months. Physical examination reveals a well-healed thyroidectomy scar, but findings are otherwise unremarkable. Serum calcitonin = 15,000 pg/ml (<8 pg/ml) (SI: 4380 pmol/l [<2.34 pmol/l]) Carcinoembryonic antigen = 65 ng/ml (<2.5 ng/ml) (SI: 65 µg/l [<2.5 µg/l]) Which of the following is the most appropriate next step in this patient s management? A. Radiolabeled calcitonin antibody therapy B. Chemotherapy with adriamycin and cisplatin C. Radiotherapy to the lung and rib lesions D. Tyrosine kinase inhibitor therapy E. Prophylactic whole-brain radiotherapy

34 58) You are called by an emergency department physician for advice in caring for a 35-year-old woman with a 5-year history of postsurgical hypoparathyroidism, previously well controlled, who has come to the emergency department after having a seizure. She is now conscious but confused. She has been out of town and without her medication for 3 days. Yesterday, she told her daughter she was having some problems with tingling and muscle spasms. Calcium = 5.8 mg/dl ( mg/dl) (SI: 1.5 mmol/l [ mmol/l]) Albumin = 3.8 g/dl ( g/dl) (SI: 38 g/l [ g/l]) Phosphate = 5.3 mg/dl ( mg/dl) (SI: 1.7 mmol/l [ mmol/l]) Magnesium = 1.9 mg/dl ( mg/dl) (SI: 0.78 mmol/l [ mmol/l]) Creatinine = 0.9 mg/dl ( mg/dl) (SI: 79.6 µmol/l [ µmol/l]) In addition to restarting treatment with oral calcium and calcitriol, which additional intravenous treatment (with cardiac monitoring) would be best? A. Calcium chloride: intravenous bolus of 0.1 ampule (1 ml of 100 mg/ml of calcium chloride) followed by a continuous infusion of 0.5 mg/kg of elemental calcium per hour B.Calcium chloride: intravenous bolus of 1 ampule (10 ml of 100 mg/ml of calcium chloride) followed by a continuous infusion of 2 mg/kg per of elemental calcium per hour C.Calcium gluconate: intravenous bolus of 2 ampules (20 ml of 100 mg/ml of calcium gluconate) followed by a continuous infusion of 1 mg/kg elemental calcium per hour D. Calcium gluconate: Intravenous bolus of 500 ml (100mg/ml of calcium gluconate) followed by a continuous infusion to achieve a total dose of 2000 mg elemental calcium over 24 hours 59) A 22-year-old woman has questions about the treatment of her diabetes mellitus. In childhood, she was told that she had elevated glucose levels, but diabetes was not diagnosed until she was 21. She has been taking metformin, 750 mg twice daily, for the last year and has intermittent bloating and loose stools. She saw a nutritionist 2 months ago to review a diet plan. Her 2-week average glucose value is 124 mg/dl (6.9 mmol/l). She has no hypoglycemia. She does not have hypertension and is not on lipid-lowering medication. Her mother was diagnosed with diabetes in her mid-teens, as was the patient s older brother. Her maternal grandfather also had diabetes. The patient s brother was found to have a mutation in the glucokinase gene (GCK). On physical examination, her height is 66 in (168 cm) and weight is 136 lb (61.8 kg) (BMI = 21.9 kg/m 2 ). Her blood pressure is 106/72 mm Hg, and pulse rate is 62 beats/min. Examination findings are normal. Hemoglobin A 1c = 5.9% (4.0%-5.6%) (41 mmol/mol [20-38 mmol/mol]) Creatinine = 0.7 mg/dl ( mg/dl) (SI: 61.9 µmol/l [ µmol/l]) Estimated glomerular filtration rate = >90 ml/min per 1.73 m 2 (>60 ml/min per 1.73 m 2 ) Electrolytes, normal TSH, normal C-peptide = 1.8 ng/ml ( ng/ml) (SI: 0.6 nmol/l [ nmol/l]) Glucose = 136 mg/dl (70-99 mg/dl) (SI: 7.5 mmol/l [ mmol/l]) Glutamic acid decarboxylase antibodies, undetectable Which of the following is the best next step in the treatment of diabetes in this patient? A. Continue metformin B. Stop metformin and continue with diet treatment C. Stop metformin and start a sulfonylurea D. Stop metformin and start a sodium-glucose cotransporter 2 inhibitor E. Stop metformin and start a glucagonlike peptide 1 analogue

35 60) Following transsphenoidal surgery, a 56-year-old woman with acromegaly has residual tumor in the clivus. Postoperative laboratory test results: GH = 9.0 ng/ml ( ng/ml) (SI: 9.0 µg/l [ µg/l]) IGF-1 = 490 ng/ml ( ng/ml) (SI: 64.2 nmol/l [ nmol/l]) Her GH and IGF-1 levels decrease by about 10% with administration of octreotide LAR, 30 mg every 4 weeks, and she remains symptomatic. Which of the following is the best treatment option to normalize her IGF-1 levels and improve her symptoms? A. Change to daily pegvisomant B. Change to lanreotide depot C. Add cabergoline, twice weekly D. Perform gamma-knife irradiation of the residual tumor 61) A 38-year-old transgender woman (male-to-female) presents to discuss gender-affirming hormone therapy. She struggled with anxiety and depression in her teenage years and 20s. She states that she drank alcohol heavily in the past, but quit completely after she had an episode of pancreatitis in her late 20s. She struggles with her weight. She recently sought psychological evaluation, and her psychologist concluded that she has gender dysphoria. At today s appointment, the patient requests estrogen therapy, and she presents a letter from her psychologist stating that the patient is ready to transition. On physical examination, her height is 71 in (180.3 cm) and weight is 215 lb (97.7 kg) (BMI = 30.0 kg/m 2 ). Her blood pressure is 136/86 mm Hg, and pulse rate is 72 beats/min. Physical examination findings are otherwise normal. You counsel the patient regarding potential adverse effects of medications and then prescribe transdermal estradiol and spironolactone. Two months later, she returns for follow-up assessment. Measurement Before therapy After 2 Months of Therapy Total cholesterol 210 mg/dl (5.44 mmol/l) 245 mg/dl (6.35 mmol/l) HDL cholesterol 26 mg/dl (0.67 mmol/l) 24 mg/dl (0.62 mmol/l) LDL cholesterol 166 mg/dl (4.30 mmol/l) Not calculated Triglycerides 204 mg/dl (2.31 mmol/l) 780 mg/dl (8.81 mmol/l) Estradiol Not measured 43 pg/ml (157.9 pmol/l) Potassium 3.6 meq/l (3.6 mmol/l) 4.2 meq/l (4.2 mmol/l) In addition to counseling regarding a low-fat diet, which of the following is the best next step in this patient s care? A. Discontinue estradiol therapy B. Change the route of estrogen administration to oral delivery C. Prescribe a fibrate D. Prescribe niacin E. Discontinue spironolactone 62) A 62-year-old man with a 10-year history of type 2 diabetes mellitus presents for cardiovascular evaluation. He has a personal 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 include 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/m 2.

36 Recent laboratory test results: Hemoglobin A 1c = 6.8% (4.0%-5.6%) (51 mmol/mol [20-38 mmol/mol]) Fasting plasma glucose = 94 mg/dl (70-99 mg/dl) (SI: 5.2 mmol/l [ 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 [<1.70 mmol/l]) LDL cholesterol = 135 mg/dl (<100 mg/dl [optimal]) (SI: 3.50 mmol/l [<2.59 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 63) An 80-year-old woman with Paget disease is referred to you for evaluation. Ten years ago, a nuclear bone scan showed increased uptake limited to the right tibia, and radiographs showed pagetic changes of the tibia. Her alkaline phosphatase level at that time was 125 U/L (2.09 µkat/l) (reference range, U/L [ µkat/l]). She has not received treatment. She now describes severe pain in her right tibia and a radiograph shows coarsened trabeculae. Her alkaline phosphatase concentration is 250 U/L (4.18 µkat/l). Her gamma-glutamyltranspeptidase level is normal. Which of the following should be the next step in this patient s evaluation? A. C-telopeptide measurement B. Percutaneous biopsy of the tibia C. Whole-body bone scan D. MRI of the right tibia 64) During her third month of pregnancy, a 26-year-old woman has developed hypertension; diabetes mellitus; hirsutism; and wide, purple striae on her abdomen. Serum cortisol (8 AM) = 37 µg/dl (5-25 µg/dl [nonpregnant patients]) (SI: nmol/l [ nmol/l]) ACTH = 129 pg/ml (10-60 pg/ml) (SI: 28.4 pmol/l [ pmol/l]) Urinary free cortisol = 475 µg/24 h (4-50 µg/24 h [nonpregnant patients]) (SI: 1311 nmol/d [ nmol/d]) MRI shows a 6-mm pituitary adenoma. Which of the following options should be recommended? A. Defer therapy until after delivery B. Begin ketoconazole C. Begin mifepristone D. Begin cabergoline E. Refer for transsphenoidal surgery 65) A 45-year-old man is referred by his primary care physician for lipid management after presenting to the emergency department with atypical chest pain a few weeks ago. Workup was negative for a cardiac etiology of chest pain. He recalls being told he had low HDL cholesterol 10 years ago, but he was never prescribed therapy. His primary

37 care physician recently diagnosed hypertension and prescribed nifedipine. He takes no other medications or supplements. The patient does not smoke cigarettes and drinks 1 alcoholic beverage per week. He is adopted and no family history is known. On physical examination, his blood pressure is 130/70 mm Hg. His height is 65.5 in (166.5 cm), and weight is 154 lb (70 kg) (BMI = 25.2 kg/m 2 ). No hepatosplenomegaly or xanthomas are noted on examination. Laboratory test results (sample drawn while fasting): Total cholesterol = 137 mg/dl (<200 mg/dl [optimal]) (SI: 3.55 mmol/l [<5.18 mmol/l]) Triglycerides = 212 mg/dl (<150 mg/dl [optimal]) (SI: 2.40 mmol/l [<1.70 mmol/l]) HDL cholesterol = 15 mg/dl (>60 mg/dl [optimal]) (SI: 0.39 mmol/l [>1.55 mmol/l]) LDL cholesterol = 80 mg/dl (<100 mg/dl [optimal]) (SI: 2.07 mmol/l [<2.59 mmol/l]) Non-HDL cholesterol = 122 mg/dl (<130 mg/dl [optimal]) (SI: 3.16 mmol/l [<3.37 mmol/l]) TSH = 2.1 miu/l ( miu/l) Plasma glucose (fasting) = 120 mg/dl (70-99 mg/dl) (SI: 6.7 mmol/l [ mmol/l]) Which of the following should be recommended now? A. A statin B. A fibrate C. Niacin D. Pioglitazone E. No therapy 66) A 42-year-old man is referred for evaluation of a low serum testosterone level. He has been troubled by decreasing libido and low energy. He has two teenaged children. On physical examination, his BMI is 23 kg/m 2. He has normal secondary sexual characteristics with no gynecomastia, striae, or acne. His testicular volume is 15 ml bilaterally. Total testosterone = 150 ng/dl ( ng/dl) (SI: 5.2 nmol/l [ nmol/l]) LH = 3.0 miu/ml ( miu/ml) (SI: 3.0 IU/L [ IU/L]) FSH = 3.0 miu/ml ( miu/ml) (SI: 3.0 IU/L [ IU/L]) Sellar CT is normal. Which of the following is the most appropriate next test? A. 24-Hour urinary free cortisol measurement B. Karyotype analysis C. Sellar MRI D. Serum epitestosterone measurement E. Serum prolactin measurement 67) A 32-year-old woman in her 16th week of pregnancy is referred for evaluation of thyrotoxicosis. She initially presented with palpitations and tremor. She has no nausea, vomiting, or abdominal pain. On physical examination, her pulse rate is 109 beats/min, and she has no ophthalmopathy. The thyroid is at the upper limit of normal size without tenderness, bruit, or nodules. Results from serial thyroid function tests are shown (see table). Time of Testing Prepregnancy 8 Weeks 12 Weeks 16 Weeks

38 Gestation Gestation Gestation Measurement TSH 0.51 miu/l miu/l <0.008 miu/l <0.008 miu/l Free T ng/dl 1.61 ng/dl 1.98 ng/dl 2.10 ng/dl (11.6 pmol/l) (20.7 pmol/l) (25.5 pmol/l) (27.0 pmol/l) Total T ng/dl 296 ng/dl (4.64 nmol/l) (4.56 nmol/l) Reference ranges: TSH, miu/l; free T 4, ng/dl ( pmol/l); total T 3, ng/dl ( nmol/l). Serum thyroglobulin is in the mid-normal range. At 12 weeks gestation, the quantitative β-hcg level was 190,450 miu/ml (190,450 IU/L) (reference range for 12 weeks gestation, 27, ,612 miu/ml [27, ,612 IU/L]). Which of the following is the most likely etiology of this patient s thyrotoxicosis? A. Surreptitious use of thyroid extract B. Graves disease C. Subacute thyroiditis D. Gestational thyrotoxicosis E. Molar pregnancy 68) A 25-year-old woman with type 2 diabetes mellitus and hypertriglyceridemia is referred for possible Cushing syndrome. She was a healthy child and had menarche at age 13 years. Soon after, she noticed gradually progressive rounding of her face. Her menses are generally irregular. On physical examination, she has moon facies, dorsocervical and supraclavicular fat pads, moderate acanthosis nigricans on her neck and axillae, and mild hirsutism. There is no facial plethora, bruises, or skin thinning. She has normal proximal and distal strength and muscular arms and legs. The liver edge is palpable just below the costal margin. Electrolytes and creatinine, normal Glucose (fasting) = 168 mg/dl (70-99 mg/dl) (SI: 9.3 mmol/l [ mmol/l]) Insulin (fasting) = 43 µiu/ml ( µiu/ml) (SI: pmol/l [ pmol/l]) Triglycerides (fasting) = 350 mg/dl (<150 mg/dl [optimal]) (3.96 mmol/l [<1.70 mmol/l]) Hemoglobin A1c = 6.2% (4.0%-5.6%) (44 mmol/mol [20-38 mmol/mol]) Plasma ACTH (8 AM) = 22 pg/ml (10-60 pg/ml) (SI: 4.8 pmol/l [ pmol/l]) Urinary free cortisol = 13 µg/24 h (4-50 µg/24 h) (SI: 35.9 nmol/d [ nmol/d]) (creatinine = 1.2 g) Serum cortisol (8 AM) after 1 mg dexamethasone at 11 PM the previous night = 0.9 µg/dl (SI: 24.8 nmol/l) Serum testosterone = 40 ng/dl (8-60 ng/dl) (SI: 1.4 nmol/l [ nmol/l]) Serum sex hormone binding globulin = 1.3 µg/ml ( µg/ml) (SI: 12 nmol/l [ nmol/l]) Which of the following is the best test to establish the diagnosis? A. [111In]-pentetreotide (octreotide) scan B. CT of the adrenal glands C. MRI of the liver D. MRI of the sella E. MRI of the legs

39 69) You are asked to see a 38-year-old man in the emergency department after he had a seizure and was found to be hypocalcemic. His height is 70 in (177.8 cm), and he has no history of calcium or bone problems. In querying about his family history, you learn that his mother died at age 25 years in a car crash that occurred after she experienced a seizure (she was reportedly otherwise healthy). The patient has 2 healthy teenaged children. Serum calcium = 6.5 mg/dl ( mg/dl) (SI: 1.6 mmol/l [ mmol/l]) Albumin = 3.8 g/dl ( g/dl) (SI: 38 g/l [ g/l]) Serum phosphate = 5.6 mg/dl ( mg/dl) (SI: 1.8 mmol/l [ mmol/l]) Serum creatinine = 0.8 mg/dl ( mg/dl) (SI: 70.7 µmol/l [ µmol/l]) PTH = 5 pg/ml (10-65 pg/ml) (SI: 5 ng/l [10-65 ng/l]) Which of the following tests is most likely to determine the diagnosis in this patient? A. Measurement of 24-hour urinary calcium B. Measurement of 25-hydroxyvitamin D C. Measurement of fibroblast growth factor 23 D. RET mutational analysis E. CASR mutational analysis 70) A 49-year-old man with a history of morbid obesity, hypothyroidism, and type 2 diabetes mellitus had a gastric bypass operation 14 months ago. His preoperative BMI was 42 kg/m 2. After surgery, his diabetes resolved and his insulin therapy was discontinued. His weight fell and stabilized at a BMI of 29 kg/m2. He was told to take a potent multivitamin and 1200 mg of calcium daily. He has not had any follow-up for the last 4 months. Over the previous 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 had developed after eating a large breakfast at a buffet restaurant. His plasma glucose level was documented to be 35 mg/dl (1.9 mmol/l). After treating the acute hypoglycemia, stabilizing his condition, and restarting home glucose monitoring, which of the following would be the most appropriate treatment to prevent a recurrent episode? A. Low-carbohydrate diet B. Partial pancreatectomy C. Octreotide D. Diazoxide 71) A 58-year-old man is admitted to the hospital for pneumonia with hypoxia. Intravenous antibiotics and oxygen therapy have been initiated, and admission is anticipated to last 3 to 4 days. He has a 20-year history of type 2 diabetes mellitus complicated by peripheral neuropathy and impaired renal function. His diabetes has been relatively poorly controlled with hemoglobin A1c values ranging from 8.2% to 9.8% (66-84 mmol/mol) over the past few years. One year ago, his regimen was transitioned to U500 insulin and his current dose is 340 units before breakfast and 280 units before his evening meal (total daily dose 620 units). Other medications include losartan, atorvastatin, aspirin, and gabapentin. He admits that he does not follow a diabetes diet, but instead grazes continuously throughout the day. His most recent hemoglobin A1c value 5 weeks ago was 8.4% (68 mmol/mol). On physical examination, he is febrile with a temperature of F (38.4 C), but he is alert and cheerful. His blood pressure is 133/95 mm Hg, pulse rate is 96 beats/min, and respiratory rate is 18 breaths/min. His height is 69 in (175.3 cm), and weight is 265 lb (120.5 kg) (BMI = 39.1 kg/m 2 ). He has general obesity with no features of lipodystrophy. A carbohydrate-consistent diabetes diet has been ordered. Which of the following is the best management plan? A. Continue U500 insulin twice daily before meals total daily dose 620 units

40 B. Continue U500 insulin twice daily before meals at 90% of home doses total daily dose 560 units C. Change to insulin glargine, 300 units once daily, and insulin aspart, 100 units with meals + correction dosing total daily dose 600 units D. Change to insulin glargine, 150 units daily, and insulin aspart, 50 units, with meals + correction dosing total daily dose 300 units + correction E. Change to intravenous insulin at 15 units/h total daily dose 360 units 72) A 32-year-old woman with polycystic ovary syndrome delivered a baby 2 years ago. During that pregnancy, she was treated for gestational diabetes with dietary restriction and was able to maintain her fingerstick blood glucose levels within the targeted range and her hemoglobin A1c level less than 6.0% (<42 mmol/mol). After delivery, her glycemia normalized. Twelve weeks postpartum, her 2-hour plasma glucose value during a follow-up oral glucose tolerance test was documented to be 136 mg/dl (7.5 mmol/l). She just learned that she is pregnant and presents for evaluation. Which of the following should you recommend? A. No intervention now; screen with oral glucose tolerance testing at 24 to 28 weeks for gestational diabetes B. Screen with oral glucose tolerance testing now for type 2 diabetes and again at 24 to 28 weeks for gestational diabetes C. Screen with hemoglobin A1c measurement now for type 2 diabetes and with oral glucose tolerance testing at 24 to 28 weeks for gestational diabetes D. Start self-monitoring of blood glucose before and 2 hours after meals 73) A 51-year-old man comes to see you for care of type 2 diabetes mellitus. His fasting lipid panel reveals the following: LDL cholesterol = 92 mg/dl (<100 mg/dl [optimal]) (SI: 2.38 mmol/l [<2.59 mmol/l]) HDL cholesterol = 42 mg/dl (>60 mg/dl [optimal]) (SI: 1.09 mmol/l [>1.55 mmol/l]) Triglycerides = 320 mg/dl (<150 mg/dl [optimal]) (SI: 3.62 mmol/l [<1.70 mmol/l]) On the basis of the current American Heart Association guidelines for the treatment of hyperlipidemia, which of the following medications would be most appropriate for this patient? A. Gemfibrozil B. Rosuvastatin C. Omega-3 fatty acids D. Rosuvastatin plus fenofibrate E. No medication needed 74) A 59-year-old man with an 18-year history of diabetes mellitus is being treated with insulin glargine and metformin. He has had longstanding hypertension, hyperlipidemia, and renal insufficiency, but no previous heart attack or stroke. His review of systems is negative. He stopped smoking cigarettes 2 years ago. He asks for recommendations to help him reduce his risk of a cardiovascular event. Both his father and paternal uncle have diabetes and developed coronary artery disease requiring stenting. His medication regimen is as follows: insulin glargine, 36 units at bedtime; metformin, 500 mg twice daily; atorvastatin; lisinopril; hydrochlorothiazide; and amlodipine. On physical examination, his blood pressure is 138/82 mm Hg and pulse rate is 88 beats/min. His height is 73.5 in (186.7 cm), and weight is 247 lb (112 kg) (BMI = 32.1 kg/m 2 ). Eye examination reveals bilateral retinal microaneurysms. On cardiac examination, he has a regular rate and rhythm, a loud S4, no S3, and no murmurs. There are no carotid bruits. His abdomen is obese with no striae or renal bruits. On neurologic examination, there is symmetric decreased light touch and vibration sense in both feet.

41 Hemoglobin A1c = 8.3% (4.0%-5.6%) (67 mmol/mol [20-38 mmol/mol]) Fasting glucose = 142 mg/dl (70-99 mg/dl) (SI: 7.9 mmol/l [ mmol/l]) Serum urea nitrogen = 31 mg/dl (8-23 mg/dl) (SI: 11.1 mmol/l [ mmol/l]) Creatinine = 1.8 mg/dl ( mg/dl) (SI: µmol/l [ µmol/l]) Estimated glomerular filtration rate = 40 ml/min per 1.73 m2 (>60 ml/min per 1.73 m2) Liver function, normal You decide to add therapy. Which of the following is the best agent for this patient? A. Premeal aspart insulin B. Glipizide C. Acarbose D. Sitagliptin E. Liraglutide 75) An 18-year-old girl presents with primary amenorrhea and short stature. Her blood pressure is 140/90 mm Hg. Her height is 56 in (142.2 cm) (BMI = 28 kg/m 2 ). She has absent breast development and scant pubic and axillary hair. FSH = 35 miu/ml ( miu/ml [follicular phase]) (SI: 35 IU/L [ IU/L]) LH = 28 miu/ml ( miu/ml [follicular phase]) (SI: 28 IU/L [ IU/L]) Estradiol = <10 pg/ml ( pg/ml [follicular phase]) (SI: <36.7 pmol/l [ pmol/l]) Karyotype = 45,X In the identification of medical problems associated with this patient s diagnosis, which of the following tests should be ordered next? A. Insulin tolerance test B. Vaginal ultrasonography C. GH stimulation test with arginine D. Thyroid ultrasonography E. Cardiac MRI 76) A 32-year-old man presents for lipid management. He reports a history of elevated cholesterol detected at age 12 years. He was prescribed colestipol and subsequently lovastatin, which he took until age 18 years. His regimen was then switched to rosuvastatin, and ezetimibe was soon added. He is adopted and family history is unknown. He does not smoke cigarettes or drink alcohol. On physical examination, his blood pressure is 124/80 mm Hg. His height is 66.5 in (169 cm), and weight is 196 lb (89 kg) (BMI = 31.2 kg/m 2 ). Xanthelasma are present over the left upper and lower eyelids, and you note several tendon xanthomas in both Achilles tendons and dorsum of the hands bilaterally. Laboratory test results are shown (samples drawn while fasting) (see table). On On Rosuvastatin, 40 mg Daily, and

42 Measurement No Therapy Rosuvastatin, 40 mg Daily Ezetimibe, 10 mg Daily Reference Ranges Total cholesterol 473 mg/dl (12.25 mmol/l) 417 mg/dl (10.80 mmol/l) 393 mg/dl (10.18 mmol/l) <200 mg/dl (optimal) (SI: <5.18 mmol/l) Triglycerides 133 mg/dl (1.28 mmol/l) 95 mg/dl (1.07 mmol/l) 97 mg/dl 1.10 mmol/l) triglycerides, <150 mg/dl (optimal) (SI: <1.70 mmol/l) HDL cholesterol 41 mg/dl (1.06 mmol/l) 38 mg/dl (0.98 mmol/l) 42 mg/dl (1.09 mmol/l) >60 mg/dl (optimal) (SI: >1.55 mmol/l) LDL cholesterol 405 mg/dl (10.49 mmol/l) 360 mg/dl (9.32 mmol/l) 332 mg/dl (8.60 mmol/l) <100 mg/dl (optimal) (SI: <2.59 mmol/l) Non-HDL cholesterol 432 mg/dl (11.19 mmol/l) 379 mg/dl (9.82 mmol/l) 351 mg/dl (9.09 mmol/l) <130 mg/dl (optimal) (SI: <3.37 mmol/l) Apolipoprotein B 285 mg/dl (2.85 g/l) mg/dl (SI: g/l) Hemoglobin A 1c 5.3% (34 mmol/mol) 4.0%-5.6% (20-38 mmol/mol) TSH 1.2 miu/l miu/l Which of the following should you add as the best next step in this patient s management? A. Evolocumab B. Niacin C. Colesevelam D. Fenofibrate E. Lipoprotein apheresis 77) A 32-year-old man has a 12-year history of type 1 diabetes mellitus. Insulin pump therapy was initiated 7 years ago. He has had reasonable glycemic control, with hemoglobin A1c levels ranging from 6.6% to 7.5% (49-58 mmol/mol) over the last 4 years. The total insulin dose per day is 32.6 units; 34% is basal insulin and 66% is bolus and correctional insulin. He is training for a half marathon, scheduled in 3 months. He runs between 5 and 12 miles in the late afternoon, 6 days per week. He usually leaves his insulin pump on when he trains and does not adjust the rate during the activity. His glucose values are in the range of 113 to 160 mg/dl ( mmol/l) immediately after most of his runs. He has noted that hypoglycemia occurs 5 to 12 hours after some of the more strenuous runs. Although he has good hypoglycemia awareness and is able to treat these nocturnal hypoglycemia episodes, he would like to avoid them if possible. Physical examination findings are normal.

43 Hemoglobin A1c = 7.1% (4.0%-5.6%) (54 mmol/mol [20-38 mmol/mol]) Creatinine = 1.0 mg/dl ( mg/dl) (SI: 88.4 µmol/l [ µmol/l]) Estimated glomerular filtration rate = >90 ml/min per 1.73 m 2 (>60 ml/min per 1.73 m 2 ) Electrolytes, normal Which of the following is the best treatment option for this patient? A. Ingest carbohydrates to increase glucose to <170 mg/dl (<9.4 mmol/l) before each strenuous run B. Lower the basal insulin rate by 50% before each strenuous run C. Skip the premeal bolus for the meal after the run D. On days of a strenuous run, lower the basal rate for 7 hours starting at bedtime E. Remove the pump before each run and restart the pump after the run 78) A 29-year-old woman with polycystic ovary syndrome returns to your clinic for a routine follow-up appointment. She has a history of obesity, hirsutism, irregular menses, and infertility, but has no current plans for pregnancy. A previous evaluation for Cushing syndrome revealed no evidence of hypercortisolism. Prediabetes was diagnosed approximately 2 years ago on the basis of an elevated fasting glucose concentration and a hemoglobin A 1c value of 5.7% (39 mmol/mol). At that time, the patient received comprehensive lifestyle education with an emphasis on weight loss through caloric restriction and regular physical activity. She reports that she exercises regularly and that she has been able to lose approximately 5% of her initial body weight, primarily by reducing her fat intake. The patient has taken metformin at a dosage of 1000 mg twice daily for the past year; she has tolerated the medication well and has had no difficulty with adherence. On physical examination, her blood pressure is 135/78 mm Hg and pulse rate is 88 beats/min. Her height is 63 in (160 cm), and weight is 317 lb (144.1 kg) (BMI = 56.1 kg/m 2 ). Her weight is unchanged from that documented at her last appointment 4 months ago. Hemoglobin A 1c = 6.1% (4.0%-5.6%) (43 mmol/mol [20-38 mmol/mol]) Sodium = 141 meq/l ( meq/l) (SI: 141 mmol/l [ mmol/l]) Potassium = 3.8 meq/l ( meq/l) (SI: 3.8 mmol/l [ mmol/l]) Creatinine = 0.7 mg/dl ( mg/dl) (SI: 61.9 µmol/l [ µmol/l]) Glomerular filtration rate = 104 ml/min per 1.73 m 2 (>60 ml/min per 1.73 m 2 ) Fasting glucose = 115 mg/dl (70-99 mg/dl) (SI: 6.38 mmol/l [ mmol/l) Which of the following is the best management plan to prevent progression from prediabetes to diabetes in this patient? A. Substitute an α-glucosidase inhibitor for metformin B. Substitute a thiazolidinedione for metformin C. Substitute a sodium-glucose cotransporter 2 inhibitor for metformin D. Recommend changing to a very low-carbohydrate diet E. Refer to a bariatric surgeon for consultation 79) A 26-year-old man returns to your clinic for management of his cystic fibrosis related diabetes mellitus. He is followed by a multidisciplinary team of providers, including a pulmonologist and endocrinologist. The patient has been married for 2 years and the couple is now interested in having a child. Neither the patient, nor his wife has attempted to have a child in the past. His wife s family has no history of cystic fibrosis and she is otherwise well with regular menses. The couple has already undergone genetic counseling and testing, and his wife was found not to be a cystic fibrosis carrier. The patient s current medications are insulin glargine once daily, insulin aspart before meals, pancreatic enzyme

44 supplements, multivitamins and a mucolytic agent. On physical examination, his blood pressure is 116/62 mm Hg. His height is 72 in (183 cm), and weight is 143 lb (65 kg) (BMI = 19.4 kg/m 2 ). Physical examination findings are unremarkable. His testes are 15 ml bilaterally without any masses. Regarding their fertility, you should advise which of the following approaches for this couple? A. Consideration of adoption as fertility is not possible for men with cystic fibrosis B. Semen collection for use with intrauterine insemination C. Semen collection for use with in vitro fertilization D. Urology referral for percutaneous epididymal sperm aspiration for use with in vitro fertilization E. Urology referral for testicular excisional biopsy with sperm extraction for use with in vitro fertilization 80) A 57-year-old woman is referred to you by her orthopedic surgeon for medical management of a bone lesion before surgical fixation. She was just evaluated for new-onset right wrist pain and deformity that occurred after an injury at work. The pain has worsened and is now refractory to anti-inflammatory medication. This has made it difficult for her to work. She received a recommendation to proceed with surgery to decrease the deformity of her bow and to stabilize the bone with plate, screw, and cement fixation. A whole-body bone scan shows markedly increased activity involving the entire right radius (see image). An x-ray shows enlargement of her right forearm with cortical thickening, trabecular coarsening, and bowing (see image).

45 She describes paresthesias in her right fingers, as well as pain that extends up to her right shoulder. She has no axillary lymphadenopathy. Her right upper extremity has an obvious distal radial deformity with an apex dorsal bow and is tender to palpation but is neurovascularly intact with no sensory deficits. Serum total calcium = 9.4 mg/dl ( mg/dl) (SI: 2.4 mmol/l [ mmol/l]) Phosphate = 3.7 mg/dl ( mg/dl) (SI: 1.2 mg/dl [ mmol/l]) Serum creatinine = 0.7 mg/dl ( mg/dl) (SI: 61.9 µmol/l [ µmol/l]) Alkaline phosphatase = 381 U/L ( U/L) (SI: 6.4 µkat/l [ µkat/l]) PTH = 47 pg/ml (10-65 pg/ml) (SI: 47 ng/l [10-65 ng/l]) Urinary N-telopeptide = 189 nmol BCE/mmol creat ( nmol BCE/mmol creat) Which of the following is the best management plan? A. Denosumab B. Palliative radiation therapy C. Surgical correction of the radius D. Intravenous zoledronic acid E. Teriparatide 81) A 22-year-old woman comes to you for follow-up of androgen insensitivity. The patient was found to have female genitalia at birth despite amniocentesis demonstrating a 46,XY karyotype. An elevated testosterone level was documented. At age 12 years, she underwent vaginal reconstruction/dilatation. The family elected not to pursue orchiectomy, and the gonadal tissue remained in the patient s abdomen. As an adult, the patient has not chosen to undergo orchiectomy based on her fear of decreased libido and her belief that the risks of malignancy are lower than those reported. On physical examination, her blood pressure is 110/80 mm Hg. Her height is 69 in (175.3 cm), and weight is 147 lb (66.8 kg) (BMI = 21.7 kg/m 2 ). On skin examination, she has no axillary or pubic hair. Her breasts are Tanner stage 5. No masses are noted on abdominal examination. Pelvic examination reveals a vaginal length of 1.5 cm. Which of the following tests is best used in monitoring this patient for gonadal malignancy? A. Abdominal ultrasonography B. α-fetoprotein measurement C. hcg measurement

46 D. Testosterone measurement E. Estradiol measurement 82) A 22-year-old woman presents to discuss treatment options for hirsutism. She had menarche at age 10 years and has always had irregular menses. Acne and abnormal hair growth began at puberty. She is currently on an oral contraceptive (ethinyl estradiol 30 mcg/norethindrone 0.5 mg). On physical examination, her BMI is 27 kg/m 2. Excess hair is observed on her upper lip, chin, and neck. No hair is present on her upper chest, upper back, or upper abdomen. She has no temporal recession of her hairline. She has scattered acne. Findings on pelvic examination are normal. Testosterone = 75 ng/dl (8-60 ng/dl) (SI: 2.6 nmol/l [ nmol/l]) DHEA-S = 297 µg/dl ( µg/dl) (SI: 8.0 µmol/l [ µmol/l]) Which of the following is the best next treatment option for improving hirsutism in this patient? A. Add flutamide B. Add spironolactone C. Change to ethinyl estradiol, 20 mcg, with levonorgestrel, 1 mg D. Change to bedtime dexamethasone 83) A 34-year-old man is referred because of weight gain of 30 lb (13.6 kg) over the past 3 years despite eating a healthful diet. He reports no skin changes or muscle weakness. He has a history of hypertension, epilepsy, and a recent diagnosis of impaired glucose tolerance. His medications include lamotrigine, carbamazepine, lisinopril, amlodipine, and atorvastatin. On physical examination, he is centrally obese. His height is 72 in (182.9 cm), and weight is 280 lb (127.3 kg) (BMI = 38.0 kg/m 2 ). There are a few pale striae over the abdominal wall but no other skin changes. There is no proximal myopathy. His blood pressure is 151/94 mm Hg. Sodium = 138 meq/l ( meq/l) (SI: 138 mmol/l [ mmol/l]) Potassium = 4.9 meq/l ( meq/l) (SI: 4.9 mmol/l [ mmol/l]) Serum urea nitrogen = 18 mg/dl (8-23 mg/dl) (SI: 6.4 mmol/l [ mmol/l]) Creatinine = 0.9 mg/dl ( mg/dl) (SI: 79.6 μmol/l [ μmol/l]) Glucose = 175 mg/dl (70-99 mg/dl) (SI: 9.7 mmol/l [ mmol/l]) TSH = 2.4 miu/l ( miu/l) Free T 4 = 1.3 ng/dl ( ng/dl) (SI: 16.7 pmol/l [ pmol/l])4free T Cortisol (8 AM, after 1-mg overnight dexamethasone suppression test) = 14 μg/dl (SI: nmol/l) In light of these results, which of the following is the most appropriate next investigation? A. Perform adrenal CT B. Perform pituitary MRI C. Measure 24-hour urinary free cortisol D. Perform a 2-day low-dose dexamethasone suppression test E. Stop lamotrigine and perform another 1-mg overnight dexamethasone suppression test 84) A 34-year-old Asian American woman presents to discuss her risk for diabetes mellitus. She feels well and has no concerns. She has no known medical conditions, and she has never been pregnant. Her only medication is a daily multivitamin. She has no known family history of diabetes and does not smoke cigarettes or drink alcohol.

47 On physical examination, her blood pressure is 126/80 mm Hg and her BMI is 24 kg/m 2. The rest of her physical examination findings are unremarkable. In addition to counseling regarding diet and physical activity, which of the following is the most appropriate next management step with respect to her diabetes risk? A. Perform screening for type 2 diabetes at age 45 years B. Perform screening for type 2 diabetes if she develops relevant symptoms such as polyuria or polydipsia C. Perform screening for type 2 diabetes now D. Schedule a return visit for one year and address her diabetes risk at that time 85) A 58-year-old postmenopausal woman is referred for evaluation of thigh pain. She has a history of low bone mass (osteopenia) treated with alendronate for 8 years. She now presents with a 2-month history of severe, deep, sharp pain in her right thigh. It is worse when she is walking but remains as a less severe ache when at rest. She has no fatigue, rash, or easy bruising. She has no history of trauma, fracture, or loss of height. On physical examination, her blood pressure is 143/82 mm Hg and pulse rate is 94 beats/min. Her height is 59 in (150 cm), and weight is 187 lb (85 kg) (BMI = 37.8 kg/m 2 ). She has no striae and no facial plethora. There is no kyphosis, no bowing of her legs, and no warmth along her legs. Pain is not elicited by rotation of the hips or with flexion/extension at the knees. Calcium = 8.8 mg/dl ( mg/dl) (SI: 2.2 mmol/l [ mmol/l]) Phosphate = 3.0 mg/dl ( mg/dl) (SI: 1.0 mmol/l [ mmol/l]) Albumin = 3.8 g/dl ( g/dl) (SI: 38 g/l [35-50 g/l]) Alkaline phosphatase = 135 U/L ( U/L) (SI: 2.3 μkat/l [ μkat/l]) 25-Hydroxyvitamin D = 19 ng/ml (25-80 ng/ml [optimal]) (SI: 47.4 nmol/l [ nmol/l]) 1,25-Dihydroxyvitamin D = 30 pg/ml (16-65 pg/ml) (SI: 78 pmol/l [ pmol/l]) Intact PTH = 63 pg/ml (10-65 pg/ml) (SI: 63 ng/l [10-65 ng/l]) Osteocalcin = 21.9 ng/ml ( ng/ml) (SI: 21.9 µg/l [ µg/l]) Serum C-telopeptide = 93 pg/ml ( pg/ml [postmenopausal women]) X-ray of the right femur is shown (see image).

48 Which of the following is the most likely cause of her femur pain? A. Bone malignancy leading to tumor-induced osteomalacia B. Prolonged bisphosphonate use C. Paget disease of bone D. Mastocytosis E. Osteomalacia from vitamin D deficiency 86) A 40-year-old woman presents with rapidly progressive hirsutism, secondary amenorrhea, balding, voice deepening, and hypertension over the last 6 months. Her primary care physician obtained some initial laboratory tests: Sodium = 143 meq/l ( meq/l) (SI: 143 mmol/l [ mmol/l]) Potassium = 3.1 meq/l ( meq/l) (SI: 3.1 mmol/l [ mmol/l]) Serum aldosterone = <2 ng/dl (1-21 ng/dl) (SI: <55.5 pmol/l [ pmol/l]) Plasma renin activity = <0.6 ng/ml per h ( ng/ml per h) Plasma ACTH = 11 pg/ml (10-60 pg/ml) (SI: 2.4 pmol/l [ pmol/l]) Serum cortisol = 14 µg/dl (5-25 µg/dl) (SI: nmol/l [ nmol/l]) Serum DHEA-S = 2833?g/dL (18-244?g/dL) (SI: 76.8?mol/L [ ?mol/L]) Serum total testosterone = 310 ng/dl (8-60 ng/dl) (SI: 10.8 nmol/l [ nmol/l]) Sex hormone binding globulin = 1.0 mg/ml ( mg/ml) (SI: 8.9 nmol/l [ nmol/l]) Which of the following is the most likely diagnosis? A. Macronodular adrenocortical hyperplasia B. Nonclassic 11β-hydroxylase deficiency C. Adrenocortical carcinoma D. Licorice ingestion E. Anabolic steroid abuse 87) A 66-year-old man is taking amiodarone for refractory atrial fibrillation. Baseline thyroid function tests are normal, but one year after starting amiodarone he develops thyrotoxicosis. On physical examination, the patient has a pulse