A 25-year-old man comes to the office with a 2-month history of palpitation, sweating, and heat intolerance.  The patient has no diplopia, eye pain or redness, decreased vision, or neck pain.  Medical history is unremarkable, and he takes no medications.  Temperature is 36.7 C (98.1 F), blood pressure is 130/70 mm Hg, pulse is 115/min (regular), and respirations are 18/min.  Examination shows mild lid-lag but no conjunctival erythema or proptosis.  Extraocular movements are intact.  Mild, diffuse, nontender enlargement of the thyroid gland is noted.  Neurologic examination demonstrates a fine hand tremor and brisk symmetric reflexes but is otherwise unremarkable.  Laboratory tests show a normal complete blood count and basic metabolic profile.  Results of thyroid function tests are as follows:

Radioactive iodine uptake at 24 hours is 36% (normal: 8%-25%), and the scan shows a diffuse uptake pattern.  Serum thyroid-stimulating immunoglobulin level is mildly elevated.

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

Item 2 of 2
Appropriate treatment is initiated.  Four weeks later, the patient returns to the office and says that his symptoms have resolved.  Blood pressure is 120/80 mm Hg and pulse is 82/min.  Eye examination shows no lid-lag.  The thyroid examination is unchanged, and the rest of the examination is unremarkable.  Which of the following is the best next step in management?

A 61-year-old man comes to the office for follow-up of long-standing type 2 diabetes mellitus.  Treatment currently consists of metformin, dietary modification, and regular exercise.  On his current regimen, the patient’s weight has been mostly stable over the last 2 years, but he has noticed some weight loss in the last 6 weeks.  He also has mild constipation but no abdominal pain, nausea, or excessive urination.  Medical history is significant for hyperlipidemia and hypertension, for which he takes atorvastatin, amlodipine, and valsartan.  He also takes low-dose aspirin and a daily multivitamin.  The patient does not drink alcohol but has a 45-pack-year smoking history.  His father had type 2 diabetes mellitus and died of a stroke, and his mother had thyroid cancer that required surgery.  Blood pressure is 134/80 mm Hg and pulse is 88/min.  BMI is 30 kg/m².  Neck examination is normal.  Lungs are clear to auscultation.  Abdominal examination reveals no masses or tenderness.  Laboratory results are as follows:

Six months ago, his chemistry profile was normal.

Item 1 of 2

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

Item 2 of 2

The patient is scheduled for additional testing but is unable to return for evaluation.  About 2 weeks after his visit, he is brought to the emergency department due to weakness, nausea, increased urination, and progressive constipation.  Blood pressure is 90/70 mm Hg and pulse is 110/min.  Mucous membranes are dry.  Laboratory results show a serum parathyroid hormone level of 9 pg/mL, serum calcium of 14.1 mg/dL, and serum creatinine of 2.6 mg/dL.  Which of the following is the most likely cause of this patient’s hypercalcemia?

A 30-year-old woman comes to the office due to tingling and numbness in both of her distal lower extremities for the last 3 months.  Her symptoms are gradually worsening.  She also has had intense fatigue.  She has not had any weight change, constipation, skin dryness, headaches, or visual changes.  The patient was diagnosed with primary hypothyroidism secondary to Hashimoto thyroiditis when she was 10 years old.  She is currently on 100 mcg per day of levothyroxine orally.  Her mother also has hypothyroidism.  The patient does not use tobacco, alcohol, or recreational drugs.  Her menstrual cycles have been irregular for the last 6 months.  Her last menstrual period was 2 months ago.  She is sexually active with one partner.  Blood pressure is 114/78 mm Hg and pulse is 72/min.  She weighs 69 kg (152 lbs) and is 163 cm (5’4″) tall.  Her thyroid is nonpalpable.  Her mucous membranes are moist and pale.  Her tongue appears to be bald.  She does not have any scleral icterus.  Vibration and proprioception are decreased in both of her lower extremities distally.  Pain and temperature sensations appear normal.  Her ankle jerks are absent, but other reflexes are brisk.  Babinski is present, and Romberg signs is positive.  The rest of the physical examination is unremarkable.  Stool obtained from the rectal examination is negative for occult blood.  Laboratory results reveal a hemoglobin of 8 g/dL and hematocrit of 24%.  Her total leukocyte count is 3,200/mm³.  Her platelet count is 300,000/mm³.  Basic serum chemistries are within normal limits.  Her total T4 level is 8.2 mcg/dL (normal 4-12 mcg/dL) and TSH level is 2.4 micro IU/mL.

Item 1 of 2

What is the next best step in the management of this patient?

Item 2 of 2

Which of the following is most crucial to monitor during the first few days of treatment in the above patient?

A 40-year-old woman comes to the clinic after noticing a small swelling in the front of her neck.  She has no pain, dysphagia, hoarseness, or difficulty breathing.  She also has no hyper- or hypothyroid symptoms such as heat or cold intolerance, fatigue, or weight changes.  Physical examination shows a mobile nodule in her left thyroid lobe.  The patient has no history of neck irradiation or family history of thyroid illness.  She currently takes no medications.  The rest of the physical examination is unremarkable.

Item 1 of 2

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

Item 2 of 2

After performing the appropriate investigation, a diagnosis of papillary thyroid cancer is made.  Which of the following is the best next step in management of this patient?

A 29-year-old woman comes to the office for evaluation of hypercalcemia.  Her serum calcium was 12.1 mg/dL on routine laboratory investigations performed for a life insurance application.  The patient feels well and has had no excessive urination, bone pain, abdominal pain, headache, or constipation.  Medical history is significant for upper gastrointestinal hemorrhage a year ago; the bleed was due to a large gastric ulcer, for which she is currently taking an oral proton pump inhibitor.  She has a 10-pack-year smoking history but does not use alcohol or illicit drugs.  The patient’s menstrual cycles are regular; she has never been pregnant, is sexually active with one partner, and uses barrier contraception to prevent pregnancy.  The patient’s mother underwent parathyroid surgery for symptomatic hypercalcemia and takes a pill twice a week for an unspecified pituitary tumor.  Blood pressure is 128/80 mm Hg and pulse is 78/min.  BMI is 27 kg/m².  Neck examination is unremarkable.  A few small subcutaneous lipomas are present on the patient’s back.  The rest of her physical examination is unremarkable.  Laboratory results are as follows:

Bone mineral density by DXA is normal.  Which of the following is the best next step in management of this patient?

A 16-year-old girl is brought to the physician by her parents.  Her mother is concerned because the girl has lost 10 pounds in the last 3 months.  She constantly feels weak and tired.  She is doing well in high school.  The patient says that she eats well, although her appetite has decreased.  Her last menstrual period was 3 months ago.  She is not sexually active.  She does not use tobacco, alcohol, or illicit drugs.  Physical examination shows a young, thin girl with multiple brown freckles.  The patient has a decreased amount of axillary and pubic hair for her age.  Patchy brown spots are seen on her lips and buccal mucosa.  Mild generalized muscular tenderness is present.  She appears well-groomed, alert, and communicative and does not appear to be especially anxious.  Her parents, on the other hand, are worried about her condition and want to know her diagnosis.

Item 1 of 2

Which of the following is the most appropriate statement regarding this patient’s case?

Item 2 of 2

The patient returns with her parents for a follow-up visit.  She complains of intermittent abdominal pain during the past week.  Examination findings remain unchanged from the previous visit.  Laboratory results are as follows:

Urinalysis is normal.  Pregnancy test is negative.  Which of the following is the most likely diagnosis?

A 38-year-old woman with a history of bipolar I disorder comes to the office due to low energy.  The patient felt well until 4 months ago when she noticed she was reacting slowly at work and was reluctant to meet with friends on weekends due to fatigue.  She is afraid she is becoming depressed again.  The patient says, “I am so discouraged.  I really felt so much better on my medication, and now I feel like I’m slipping.”  She has a history of multiple hospitalizations for manic and depressive episodes since late adolescence.  She attempted suicide at age 20 by taking an overdose of aspirin.  The patient was previously treated with valproate and olanzapine and has been taking lithium for the past year.  Her other medical issues include hypertension and allergic rhinitis, for which she takes hydrochlorothiazide and loratadine, respectively.  On review of systems, the patient reports fatigue and difficulty concentrating over the past few weeks.  Mental status examination shows a tired appearance and sad affect.  She has no suicidal ideation.  Physical examination shows no abnormalities.  The patient’s blood lithium level is 0.9 mEq/L (range: 0.6-1.2 mmol/L).  Other laboratory results are as follows:

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

A 36-year-old woman comes to the office due to a 5-month history of progressive lower back pain.  The pain is aching and nonradiating and has no aggravating or relieving factors.  Two years ago, the patient underwent Roux-en-Y gastric bypass surgery for morbid obesity, after which she lost 45.4 kg (100 lb).  She follows a normal diet and takes a daily multivitamin containing calcium (1,200 mg of elemental calcium) and vitamin D (400 IU of cholecalciferol).  Spinal examination shows no focal tenderness.  Laboratory results are as follows:

Bone mineral density by DXA reveals a T-score of −2.0 at the lumbar spine and −1.5 at the hip.  Which of the following is the best next step in management of this patient?

A 64-year-old woman comes to the physician because she has had bilateral foot numbness and burning for the past three months.  The symptoms are especially bothersome at night.  She has a history of hypertension, coronary artery disease, and type 2 diabetes mellitus.  She had an anterior wall myocardial infarction two years ago, which was treated with angioplasty and stenting of the left anterior descending artery. An echocardiogram obtained one year ago revealed an ejection fraction of 40%.  She does not use tobacco, alcohol, or drugs.  Her medications include metoprolol, furosemide, glyburide, atorvastatin, aspirin, and enalapril.  She has been on oral hypoglycemic medications for the last ten years.  Her blood pressure is 142/82 mmHg and her heart rate is 63/min.  Her BMI is 34 kg/m².  Physical examination shows intact skin over both feet and 2+ peripheral pulses.

Item 1 of 2

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

Item 2 of 2

The patient returns two months later for follow-up.  She has persistent symptoms and complains of poor sleep.  Her last HbA1c was 7.9% and creatinine was 0.9 mg/dL.  Urinalysis shows trace proteinuria.  Which of the following is the best management option for this patient?

A 29-year-old man comes to the emergency department complaining of palpitations, sweating, and severe headache.  His symptoms resolve spontaneously by the time he is evaluated.  He has had at least 2 similar episodes during the past 2 months.  The patient’s family history is unremarkable.  He does not use tobacco, alcohol, or illicit drugs.  His primary care provider saw him after the first episode and prescribed an anxiolytic medication.  However, the patient felt drowsy at his job and stopped the medication.  Physical examination shows a thin man who appears anxious and diaphoretic.  The thyroid is normal to palpation without any obvious nodules.  His temperature is 36.7 C (98 F), blood pressure is 126/84 mm Hg, pulse is 86/min, and respirations are 16/min.  During his prior emergency department visit for an identical episode, his blood pressure was 150/100 mm Hg and pulse was 120/min.  The laboratory results at that time showed normal thyroid function tests.

Item 1 of 3

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

Item 2 of 3

Endocrine studies yield results highly suspicious of a neuroendocrine tumor.  Which of the following is the best next step in management of this patient?

Item 3 of 3

The patient is placed on appropriate preoperative medications and is taken for surgical removal of the tumor.  During the procedure, he rapidly becomes hypotensive.  His blood pressure falls from 110/89 mm Hg to 80/50 mm Hg.  Which of the following is the most appropriate therapy for this patient’s hypotension?

A 31-year-old woman, gravida 1 para 1, comes to the office 5 weeks after an uneventful vaginal delivery.  The patient has fatigue, sweating, and heat intolerance.  She has had no skin rash, headache, vision changes, or ocular symptoms, and her appetite is normal.  The patient is not breastfeeding because her milk supply rapidly diminished.  She has not yet resumed normal menstruation.  Medical history is unremarkable, and her only medication is a daily prenatal vitamin that she continued following delivery.  The patient’s mother has hypothyroidism and celiac disease.  Blood pressure is 121/67 mm Hg and pulse is 109/min.  Examination shows an enlarged, nontender thyroid gland with no nodules.  Ocular examination shows mild lid lag without proptosis.  The remainder of the examination is unremarkable.  Laboratory results are as follows:

The radioactive iodine uptake in the thyroid gland is 1.5% at 24 hours (normal: 8%-25%).  Which of the following is the most likely diagnosis?

A 60-year-old woman comes to the office for follow-up of type 2 diabetes mellitus.  She has been taking metformin for the past 2 years with a gradual rise in hemoglobin A1c.  Medical history includes hypertension and diabetic nephropathy with moderately increased albuminuria.  In addition to metformin, her medications include lisinopril and atorvastatin.  Blood pressure is 136/90 mm Hg and pulse is 76/min.  BMI is 37 kg/m².  Laboratory results are as follows:

Treatment with canagliflozin is started.  Which of the following metabolic effects is most likely to occur due to treatment in this patient?

A 31-year-old man with type 1 diabetes mellitus is brought to the emergency department due to abdominal discomfort, nausea, and vomiting.  He has not felt well for the past 2 days and has had intractable vomiting.  The patient stopped taking his regular dose of insulin because he was unable to “hold anything down.”  Initial laboratory results show positive serum ketones, blood glucose of 360 mg/dL, and blood pH of 7.17.  In the emergency department, he is started on intravenous normal saline with potassium and a continuous insulin infusion.  Five hours after admission to the intensive care unit, he feels better.  Laboratory results are as follows:

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

Item 2 of 2
Ten hours after admission, the patient feels better.  He has had no vomiting over the last several hours, and his abdominal discomfort has subsided.  He is tolerating oral fluid.  The patient is currently on an insulin infusion and intravenous fluids.  Repeat laboratory results are as follows:

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

A 56-year-old woman comes to the physician with lethargy, weight loss, nausea, vomiting, and constipation for the past 2 months.  She is 3 years postmenopausal and has no long-standing medical problems.  The patient currently takes no prescription medications and does not use tobacco or alcohol.  Her family history is positive for osteoporosis and hypertension.  Her blood pressure is 124/66 mm Hg and pulse is 64/min.  She weighs 63 kg (138 lb) and is 160 cm (5′ 3″) tall.  Her body mass index is 24.4 kg/m².  The patient appears mildly pale.  The thyroid gland is normal to palpation.  Heart and lung sounds are normal.  Abdominal examination is unremarkable.  Neurologic examination shows prolonged relaxation time of the ankle reflexes.  Laboratory results are as follows:

Red blood cells are normochromic and normocytic.  The 8:00 AM serum cortisol is 7 µg/dL (normal 5-20 µg/dL).  Repeat thyroid function tests show similar results.

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

A 16-year-old boy is evaluated by the medical team in the intensive care unit.  He was admitted 3 weeks ago following a motor vehicle accident.  The patient sustained a C5-C6 fracture with dislocation, which resulted in quadriplegia.  He currently has a tracheostomy tube and requires mechanical ventilation, and is being fed by a percutaneous endoscopic gastrostomy tube.  A week ago, the patient was diagnosed with ventilator-associated pneumonia, which is being treated with piperacillin-tazobactam.  His mother says that before his injury he was trying to “build up his muscles” by drinking protein shakes and taking creatine supplements.  Medical history is otherwise unremarkable.  The patient’s mother has Graves disease and his father has hypertension.  He has no siblings.  Blood pressure is 124/70 mm Hg and pulse is 64/min.  Coarse crackles are heard at the right lung base.  Laboratory results are as follows:

Repeat testing confirms these values.  Ionized calcium level is 6.6 mg/dL (normal: 4-5.6 mg/dL).  Which of the following is the most likely cause of this patient’s hypercalcemia?

A 38-year-old woman comes to the office due to type 2 diabetes mellitus.  She has been treated with metformin and dietary modification for the past 2 years, and her glycemic control has gradually worsened.  Medical history includes obesity.  Treatment with semaglutide is begun.  The patient returns for follow-up after 3 months of treatment with the new drug, and the following results are observed:

Which of the following is most likely contributing to the decreased BMI in this patient?

A 47-year-old Caucasian man comes to the office for a follow-up visit.  He was recently diagnosed with diabetes mellitus type 2, and was started on a low-carbohydrate diet six months ago.  He also has obesity, hypertension and hyperlipidemia.  He is a financial advisor.  He does not use tobacco or illicit drugs, but drinks alcohol occasionally.  His medications include enalapril, simvastatin and hydrochlorothiazide. Examination shows no abnormalities.  His laboratory test results show the following:

Serum Chemistry

LFT

Lipid Profile

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

A 74-year-old man is brought to the emergency department after being found outside early on New Year’s morning.  His medical history is unknown.  Temperature is 31.5 C (88.7 F), blood pressure is 75/50 mm Hg, pulse is 55/min, and respirations are 8/min and shallow.  On examination, the patient is unresponsive.  Initial laboratory results are as follows:

Blood alcohol level is undetectable and urine drug screen is negative.  Plasma cortisol and ACTH levels are normal.  Chest x-ray reveals a right lower lobe infiltrate.  The patient is placed on mechanical ventilation, pressor support, warm intravenous fluids, and broad-spectrum antibiotics.  Blood cultures are pending.  His vital signs improve rapidly with rewarming.  Which of the following is the best next step in management of this patient’s thyroid abnormalities?