A 25-year-old man comes to the emergency department because of headache, palpitations, sweating, and irritability.  He came directly from the health club, which he joined a few weeks ago.  He states that after every exercise session during evening, before dinner, he develops similar symptoms and he gets symptomatic relief by consuming granola bars.  He was diagnosed with type 1 diabetes mellitus eight years ago.  He takes a combination of NPH and regular insulin before breakfast and supper.  He states that he is very compliant with his insulin and meals.  He does not have any other symptoms or chronic complications of diabetes.  His blood pressure is 110/80 mmHg, pulse is 100/min, temperature is 36.7C (98F) and respirations are 14/min.  He is slightly diaphoretic but completely alert and awake.  His neurological examination is nonfocal.  The rest of the examination is unremarkable.

Item 1 of 2

Hypoglycemia is defined as a plasma glucose level of:

Item 2 of 2

Which of the following is the most appropriate step to prevent further hypoglycemic episodes in this patient?

A 68-year-old woman comes to the emergency department due to a month-long history of increasing palpitations.  She has had no associated chest pain or shortness of breath but has experienced unusual fatigability.  The patient has also noted a 4-kg (8.8-lb) weight loss on her home scale and has been waking with increasing frequency at night to urinate.  She was diagnosed with osteopenia on bone densitometry at age 65; she increased her intake of “milk, yogurt, cheese, and other foods with lots of calcium” and started a vitamin D supplement, but repeat DXA 2 months ago revealed a significant interval decline in bone density.  The patient’s medical history is otherwise unremarkable, and she does not use tobacco, alcohol, or illicit drugs.  Her mother died of breast cancer at age 62 and her father died in a motor vehicle collision at age 40.  Temperature is 36.7 C (98 F), blood pressure is 151/68 mm Hg, pulse is 122/min, and respirations are 16/min.  The thyroid gland is diffusely enlarged and nontender.  Lid lag is noted on eye examination.  The lungs are clear to auscultation.  The heart has an irregularly irregular tachycardia with a variable intensity of S1.  Laboratory results are as follows:

Which of the following should be addressed next in treatment of this patient’s condition?

A 40-year-old man is brought to the emergency department for sudden onset of headaches, diaphoresis, and loss of consciousness.  His wife states that he was previously in his usual state of health.  His past medical history is unremarkable.  He works as a physician assistant and does not smoke or drink alcohol.  On physical examination, the patient is diaphoretic and comatose.  His fingerstick blood glucose level is 45 mg/dL.  The patient is given 50% dextrose intravenously and then regains consciousness.  He says that he is currently dealing with a great deal of work- and relationship-related stress.

Laboratory test results on the blood sample drawn prior to dextrose administration are as follows:

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

A 67-year-old man comes for follow-up of coronary artery disease.  He is currently feeling well.  Three months ago, he was hospitalized for chest pain; coronary angiography revealed 85% narrowing in the mid right coronary artery, and a drug-eluting stent was placed.  In addition, TSH was noted to be low.  The patient now walks 2-3 miles a day without angina, dyspnea, or lower extremity claudication.  He states, “I am very happy that I lost 5 lb since my hospitalization.  I also gave up smoking and drinking.  I feel like I got my life back.”  Current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin.  The patient’s father died from a heart attack at age 56, and his mother has osteoporosis and hypertension.  Blood pressure is 134/76 mm Hg and pulse is 65/min.  BMI is 28 kg/m².  Physical examination, including examination of the thyroid gland, is normal.  Repeat thyroid function results are as follows:

Radioactive iodine uptake is increased, with a homogeneous distribution on thyroid scan.  Which of the following is the most appropriate management for this patient?

A 35-year-old woman is being evaluated for uncontrolled hypertension.  She was recently diagnosed with diabetes mellitus.  Medical history is significant for mood swings.  Temperature is 36.7 C (98 F), blood pressure is 150/100 mm Hg, pulse is 88/min, and respirations are 14/min.  Lungs are clear on auscultation bilaterally, and the heart rhythm is regular.  Abdominal auscultation fails to reveal any bruit.  All peripheral pulsations are full.  Laboratory results are as follows:

Chest x-ray is suggestive of dorsal vertebral osteopenia.  Which of the following is the most appropriate investigation?

A 54-year-old woman comes to the emergency department with palpitations.  She has experienced paroxysmal atrial fibrillation for the past 6 months.  She has had extensive investigations for an underlying cause, including echocardiography and thyroid function testing, which were normal.  The patient was started on amiodarone 6 weeks ago by her cardiologist and did well in the interim.  She has had no change in her weight or intolerance to hot or cold temperatures.  Her other medications include atenolol and low-dose aspirin.  On physical examination, the patient appears comfortable.  Her blood pressure is 132/82 mm Hg and heart rate is 112/min and irregular.  Laboratory studies show a normal complete blood count and basic metabolic panel.  ECG shows atrial fibrillation with rapid ventricular response.  Thyroid function markers are as follows:

Item 1 of 2

What is the most likely explanation for this patient’s thyroid function tests?

Item 2 of 2

What is the best management for this patient?

A 45-year-old man comes to the clinic for follow-up of hypertension.  The patient has been taking lisinopril since the condition was diagnosed 6 months ago.  He has a 10-pack-year history; he quit smoking 5 years ago.  Medical history includes laparoscopic cholecystectomy 5 years ago after an episode of acute cholecystitis.  The patient does not consume alcohol.  His father had a heart attack at age 62, and his mother died of a stroke at age 67.  Blood pressure is 130/80 mm Hg and pulse is 67/min.  BMI is 30 kg/m².  Physical examination is unremarkable.  Fasting laboratory results are as follows:

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

A 65-year-old female is admitted to the intensive care unit for chest pain where she is diagnosed with a non-ST elevation myocardial infarction.  She has a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, and osteoporosis.  Over the last two months, she has been getting occasional chest pain on exertion.  She also complains of some recent fatigue and mild constipation.  Cardiac catheterization is performed and shows severe triple-vessel coronary artery disease.  A coronary artery bypass graft procedure (CABG) is planned.  Her laboratory values include the following:

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

A 19-year-old man comes to the office for a new patient visit.  Three months ago, he was seen at an urgent care clinic due to fatigue, excessive urination, and unexpected weight loss.  Laboratory evaluation at that time showed a serum glucose level of 384 mg/dL, normal anion gap, and hemoglobin A1c of 10.4%.  Regular insulin was prescribed, which the patient takes before meals, and insulin glargine, which he takes at night.  The patient checks his blood sugar 3 times daily; home glucose levels usually range from 100 to 300 mg/dL but have been as low as 65 mg/dL.  He consumes a diabetic diet and tracks carbohydrate counts appropriately.  He does not exercise.  BMI is 24 kg/m².  Physical examination, including monofilament testing of the feet, is normal.  Laboratory results are as follows:

Which of the following is the best next step to promote optimal glycemic control in this patient?

A 24-year-old woman comes to the office due to localized swelling in the front of her neck.  She has had no associated pain, difficulty swallowing, or voice changes.  The patient is otherwise healthy and takes no medications; she has no history of radiation exposure or family history of thyroid disease.  Physical examination shows firm swelling in the right side of the thyroid gland.  Serum TSH and free thyroxine levels are normal.  Thyroid ultrasonography reveals a solid nodule measuring 2.6 × 1.7 × 1.3 cm in the right lobe; the left lobe is normal in size and echotexture.

Item 1 of 2
Which of the following is the best next step in management of this patient?

Item 2 of 2
Fine-needle aspiration biopsy of the nodule shows nests of polygonal cells with extracellular, Congo red–positive amyloid deposits, findings consistent with medullary thyroid cancer.  Serum calcitonin is 300 pg/mL (normal: 0-10).  Genetic studies show a mutation in the RET protooncogene.  Which of the following is the best next step in management of this patient?

A 26-year-old woman comes to the office due to fever, sweating, heat intolerance, and shortness of breath.  Her symptoms began a week ago and have become progressively worse.  The patient has also had severe pain in the anterior neck, which radiates to the angle of the jaw and ears and is worse when she turns her head.  She adds that she has “been under a lot of stress lately since I was laid off from my job.  I have been babysitting to make some extra money, but I think one of the kids gave me ‘the flu.’  I had a runny nose, cough, and fever a few weeks ago.”  Medical history is unremarkable, and the patient takes no medications.  She has smoked a pack of cigarettes a day for the last 7 years, and smoked marijuana for a few months as a teenager.  The patient is not sexually active and has never been pregnant.  Her last menstrual period was 2 weeks ago.  She is adopted, and her family history is unknown.  Temperature is 38.3 C (100.9 F), blood pressure is 156/60 mm Hg, pulse is 110/min, and respirations are 22/min.  The thyroid gland is diffusely enlarged, firm, and very tender.  The extremities are warm and moist.  Eye examination shows lid lag but no proptosis.  The remainder of the examination is unremarkable.  Laboratory results are as follows:

Item 1 of 2

A radioactive iodine uptake with scintigraphy in this patient is mostly likely to show which of the following?

Item 2 of 2

Which of the following is the best treatment for this patient?

A 30-year-old woman comes to the office due to tiredness for the past 3 months.  She has been unable to exercise due to excessive fatigue and muscle cramps.  The patient has had no cold intolerance, constipation, or dry skin.  She states, “My menstrual cycles have been unpredictable and very heavy.”  Medical history is notable for episodic migraines, for which she began taking topiramate 6 months ago.  The patient initially had significant weight loss after starting topiramate, but she has regained most of the weight over the last 2 months and continues to have occasional migraines.  She also has a history of chronic anxiety and an episode of nephrolithiasis a few months ago.  The patient lives alone, is not sexually active, and has had no pregnancies.  She does not use tobacco, alcohol, or illicit drugs.  The patient’s sister underwent a thyroidectomy for unknown reasons.  Blood pressure is 136/80 mm Hg and pulse is 68/min.  BMI is 28 kg/m².  The thyroid gland is normal in size and nontender.  Deep tendon reflexes are normal; the remainder of the examination is unremarkable.  Serum TSH is 5.7 µU/mL.  Repeat TSH a month later is 5.6 µU/mL, and free T4 is normal.

Item 1 of 2

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

Item 2 of 2

Which of the following additional findings is most likely to be associated with this patient’s condition?

A 66-year-old man is found to have bilateral breast enlargement during a routine office visit.  The patient reports no breast discomfort, headaches, or vision abnormalities but has had decreased libido and lack of energy for several months.  Medical conditions include hypertension, hyperlipidemia, and osteoarthritis.  The patient takes chlorthalidone, simvastatin, and acetaminophen as needed.  He does not use over-the-counter or herbal supplements.  The patient drinks 1 or 2 alcoholic beverages during social events and does not use tobacco or recreational drugs.  He is married and has several adult children.  Family history is notable for breast cancer in a maternal aunt.  Vital signs are within normal limits.  BMI is 32 kg/m².  Examination shows normal body hair distribution and no rashes.  Breast examination demonstrates 2-cm, round, firm tissue behind the areolas bilaterally with no overlying skin changes or nipple discharge.  There are no enlarged lymph nodes.  External genitalia are normal in size and appearance, and no testicular masses are present.  The remainder of the physical examination is normal.  Laboratory results are as follows:

Serum chemistry panel and liver aminotransferases are within normal limits, and serum testosterone level is unchanged on repeat testing.  Which of the following is the most likely explanation for this patient’s breast abnormality?

A 37-year-old woman comes to the office for evaluation of fatigue and lower extremity edema for the past 3 weeks.  She has had type 1 diabetes mellitus for 20 years.  Current medications include basal and bolus insulin, atorvastatin, and lisinopril.  Blood pressure is 158/90 mm Hg and pulse is 80/min.  Examination shows 2+ bilateral pitting lower extremity edema and is otherwise normal.  Laboratory results are as follows:

At her last office visit six months ago, serum creatinine was 1.1 mg/dL, eGFR was 64 mL/min/1.73 m², and urine albumin/creatinine ratio was 500 mg/g.  Which of the following is the most appropriate next step in management of this patient?

A 59-year-old woman comes to the clinic due to a 2-month history of fatigue, myalgias, and bone pains.  She has also experienced a 4.5-kg (10-lb) weight gain over the past year, which she attributes to physical inactivity and changes in her diet since immigrating to New York City from India to live with her son.  Medical history is notable for alpha-thalassemia-1 trait, and the patient experienced menopause at age 49.  She takes no medications or supplements.  Vital signs are normal.  BMI is 32 kg/m².  Physical examination is unremarkable.  Laboratory results are as follows:

Which of the following is the most appropriate next step?

A 23-year-old woman comes to the office due to recurrent hypoglycemia.  The patient has a 6-year history of type 1 diabetes mellitus that has been treated with a stable dose of insulin in a basal-bolus regimen.  However, for the last 3 months, she has had frequent episodes of hypoglycemia distributed evenly throughout the day; she has also had fatigue, loss of appetite, amenorrhea, and a 2-kg (4.4-lb) weight loss.  The patient has had no change in activity and has experienced no fever or gastrointestinal, genitourinary, or respiratory symptoms.  She is not sexually active and does not use tobacco, alcohol, or recreational drugs.  Blood pressure is 90/60 mm Hg and pulse is 100/min.  BMI is 20 kg/m².  Physical examination is unremarkable.  Laboratory results are as follows:

ECG and urinalysis are unremarkable.  In addition to decreasing the patient’s insulin dose, which of the following is the most appropriate course of action in management of this patient?

A 36-year-old man comes to the office after he was found to have an abnormal lipid panel during employee wellness testing at his company.  He has no prior medical problems and takes no medications.  The patient is a software technician and has a sedentary lifestyle.  He eats mostly fast foods, rarely exercises, and drinks 2-3 cans of beer daily.  His BMI is 31 kg/m².  Physical examination is unremarkable.  Results of laboratory studies performed in the office are as follows:

Lifestyle modification with a balanced diet, regular exercise, and reduced alcohol intake is advised.  He is also started on fenofibrate therapy.  This medication is most likely to help the patient by which of the following mechanisms?

A 26-year-old woman, gravida 1 para 0, at 16 weeks gestation comes to the clinic for follow-up prenatal care.  She was diagnosed with Graves disease during her first trimester and was treated with propylthiouracil, which was changed to methimazole 3 weeks ago.  The patient has gained 7 kg (15.4 lb) over the last 4 months.  She also has experienced increasing fatigue and states, “My breasts feel very full.”  The patient has had no palpitations or shortness of breath, but her sleep has been interrupted by frequent urination.  Her mother has hypothyroidism, which is treated with levothyroxine.  The patient has never used tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 112/72 mm Hg, pulse is 90/min and regular, and respirations are 18/min.  No murmurs are heard on cardiac auscultation.  Thyroid examination shows mild, diffuse enlargement with no tenderness or bruit.  Deep tendon reflexes are brisk but symmetrical.  The remainder of the physical examination is normal.  Thyroid function test results are as follows:

Which of the following is the most appropriate management for this patient?