- A 30 year old woman presents with a painful neck mass. She was well until approximately two weeks ago when she developed an upper respiratory infection with nasal congestion, headaches, and mild cough. She developed pain, redness, and mild swelling in the anterior portion of her neck around the "Adam's Apple" about three days ago. She has had mild fevers and headahces, felt nervous and "jittery". On examination, she appears tremulous and anxious. Her blood pressure is 135/85, pulse 110, respirations 16, and temperature is 99.5°F. Physical examination is significant mild swelling and pain with erythema over the thyroid area. There is mild left sieded cervical lymphadenopathy. Neck range of motion is slightly decreased. Her chest is clear. Heart has a bounding apical impulse at the midclavicular line, and there is a soft S4 gallop at the apex. The remainder of the examination is normal except for a mild resting tremor. The most likely diagnosis is [1]:
- A. Hashimoto's Thyroiditis
- Which set of laboratory values is most likely to be associated with this patient [2] ?:
A. TSH 0.2 (low) Total T4 14µg/dl (elevated) Free Thyroxine Index (FTI) 12 (elevated)
B. TSH 0.9 Total T4 8µg/dl (normal) FTI 8
C. TSH 6 Total T4 6µg/dl (normal) FTI 6
D. TSH 12 (high) Total T4 4µg/dl (low normal) FTI 4 (low)
E. TSH 20 Total T4 3µg/dl (low) FTI 2 (low) - The patient is sent home on a low dose of propranolol which improves the tremor and decreases the heart rate. She returns 4 days later with decreased neck pain, increased tremor, a blood pressure of 155/60, pulse irregular at135 bpm, temperature 101.5°F, respirations 30 per minute. There is a mild headache and she is having difficulty concentrating. The most likely diagnosis is [3]:
A. Graves' Disease
B. Hashimoto's Thyroiditis
C. Thyroid Storm
D. Pheochromocytoma
E. Pituitary Adenoma - A 47 year old patient with 20 years of Type I Diabetes Mellitus presents to the emergency room with lethargy, confusion, nausea, vomiting, abdominal pain, and tachypnea. The blood pressure is 140/90 mm (equal right and left), pulse 110 bpm, respirations 32/minute, temperature 101.5°F. The physical exam is notable only for tachycardia and a 5cm wide, 1cm deep ulcer on the medial aspect of the right foot, near the first MTP joint. The surrounding area is inflamed and tender. A rapid blood glucose test returns at 547mg/dL. An arterial blood gas shows a pH of 7.12, pO2 100mm, pCO2 20mm. Urine dips positive for glucose, ketones, and red blood cells. The best therapy and further diagnosis is [4]:
A. Electrocardiogram (ECG), Blood Cultures, IV insulin bolus and drip, antibiotics
B. ECG, blood cultures, IV insulin bolus and drip, intravenous fluids, and antibiotics
C. Blood cultures, IV insulin bolus and drip, intravenous fluids, and antibiotics
D. Urine culture, ECG, IV insulin bolus and drip, intravenous fluids, and antibiotics
E. Wound culture, IV insulin bolus and drip, intravenous fluids, and antibiotics - The serum potassium drawn prior to therapy returns at 6.7mg/dL (non-hemolyzed). There is no ventricular ectopy on a rhythm strip. The appropriate action is [5]:
A. Immediately give 2 amps of sodium bicarbonate and additional insulin iv
B. Immediately give 40mg of intravenous furosemide and 2 amps of sodium bicarbonate
C. Administer sodium polystyrene sulfonate (Kayexelate®) per nasogastric tube
D. Increase intravenous fluid rate and give 2 amps of sodium bicarbonate
E. Obtain another blood sample to assess the impact of therapy on the potassium level - The patient does well over the next 24 hours. The blood glucose is 180mg/dL. The urine is negative for ketones. The anion gap is 20mM (normal <16mM). The serum ketones are trace positive. The next step is to [6]:
A. Stop the intravenous insulin drip and administer subcutaneous insulin
B. Begin D5W intravenously, turn down the insulin drip, and carefully monitor glucose
C. Begin D5W intravenously, stop the insulin drip, and begin subcutaneous insulin
D. Stop the intravenous insulin drip and monitor the glucose level
E. Stop the intravenous insulin drip, begin subcuteneous insulin, and administer D5W - A 28 year old man is referred to you for further evaluation of new onset diabetes mellitus requiring insulin. There is a grandfather with type II diabetes mellitus, but no other family history. The patient is otherwise well. Routine screening laboratories are normal except for mildly elevated transaminases (AST/SGOT and ALT/SGPT), each about 2X normal. The next test to order is [7]:
A. Hepatitis Virus Serologies
B. Ceruloplasmin Level
C. Ethanol Level
D. Iron and Ferritin Levels
E. Liver Biopsy - A 20 year old woman presents with recent onset of weight gain, hirsutism and oligomenorrhea. The appropriate screening laboratory tests include [8]:
A. Serum Androgen Levels (eg. testosterone, DHEA, DHEA-S)
B. Serum Prolactin
C. Urinary Androgen Levels
D. Serum Follicle Stimulating (FSH) and Luteinizing (LH) Hormone Levels
E. Serum Insulin-like Growth Factor (IGF-1) Levels - A 62 year old women is brought into the hospital with dehydration and lethargy. She has a history of mild systolic hypertension treated with a thiazide diuretic for several years. Physical examination is notable for a lethargic elderly woman without asterixis. Vital signs are normal and there is mild left costovertebral angle tenderess on palpation; otherwise, exam is normal. A serum calcium level is 12mg/dL (normal <9mg/dL with normal albumin) and her albumin is 4.2gm/dL (normal 3.6-5.1gm/dL), globulin 2.7gm/dL (normal). The blood urea nitrogen is 30mg/dL, creatinine 0.8mg/dL, phosphate 1.8mg/dL (normal 2.5-4.5) and the electrolytes are otherwise normal. The complete blood count is normal. A urine dipstick shows small red cells, white cells, and few bacteria without any protein. An abdominal radiograph reveals a small calcified density in the region of the left kidney. The most likely cause for this patient's hypercalcemia is [9]:
A. Hyperparathyroidism
B. Hyperthyroidism
C. Thiazide diuretic overdose
D. Multiple Myeloma
E. Non-Hodgkin's Lymphoma - Which of the following treatments is NOT an effective therapy for hypercalcemia [10] ? A. Loop Diuretics
B. Grave's Disease
C. Subacute Thyroiditis
D. Post-Partum Thyroiditis
E. DeQuervaine's Thyroiditis
B. Thiazide Diuretics
C. Calcitonin
D. Bisphosphonate Therapy
E. Intravenous Fluids
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- E (DeQuervaine's Thyroiditis is painful and more acute than the others)
- A (Usually associated with mild hyperthyroidism)
- C
- B (An ECG should be done on all patients with decompensated diabetes)
- E (Insulin will increase potassium entry into cells and significantly reduce serum levels)
- B (Intravenous insulin should not be stopped in the continued presence of ketosis or anions)
- D
- A (The likely diagnosis is Polycystic Ovary Syndrome or Chronic Anovulatory Syndrome)
- A (Absence of systemic signs and of renal dysfunction)
- B (Thiazide diuretics cause calcium retention and can lead to hypercalcemia)