A 48-year-old man comes to the clinic with symptoms of sexual dysfunction.
He states that for the last year and a half, he has had a markedly decreased
libido and trouble maintaining an erection. He has also occasionally noticed
some milky-type of discharge from his nipples. He denies headaches,
shortness of breath, or chest pain. He has had no abdominal or urinary
symptoms. He has no significant past medical history and takes no
medications. On physical examination, he is afebrile and has normal vital
signs. His visual acuity, visual fields, extraocular movements, and pupillary
response to light are normal. Remainder of neurologic examination is normal.
Laboratory studies show a leukocyte count of 5,600/mm3, hematocrit 45%,
platelets 230,000/mm3, glucose 100 mg/dL, creatinine 0.8 mg/dl, blood urea
nitrogen 16 mg/dl, serum prolactin 1,000 ng/ml (normal <20 ng/ml). The next
most appropriate step in management is
A. bromocriptine
B. mammography
C. a MRI of the brain
D. a MRI of the lumbar spine
E. sildenafil citrate
Explanation:
The correct answer is C. This patient has impotence, loss of libido, and
galactorrhea related to hyperprolactinemia. The most common cause of this
in men is probably medication induced, however, he is on no medications.
The next main thing to rule out is a prolactin secreting microadenoma by an
MRI of the brain.
Bromocriptine (choice A) may end up being the treatment of choice for this
patient if a microadenoma is found. However the diagnosis should be made
prior to treatment. If bromocriptine therapy fails to relieve symptoms, or if the
adenoma grows/begins causing other symptoms, referral to neurosurgery to
evaluate for transphenoidal resection would be warranted.
There is no indication for a mammogram (choice B) or an MRI of the lumbar
spine (choice D) in this case.
Sildenafil (choice E) also may end up being helpful in this case for the
patient's symptoms. However, again making the underlying diagnosis is the
most appropriate first step in the work up.
A 23-year-old woman comes to the clinic for a pre-employment examination. She
recently moved to the area from out of state and got a job at a local small business. Her
past medical history is significant only for diabetes mellitus type I, which she has had
since age 13. Her only medication is insulin, which is infused via an insulin pump. She
denies smoking or using illicit drugs. She admits to social alcohol consumption less than
once a week and says she runs 2 miles daily. She is not sexually active. You perform a
1
full physical examination. Her temperature is 37.1 (98.8 F), blood pressure is 136/89 mm
Hg, pulse is 54/min, and respirations are 12/min. Her skin is warm and dry.
Cardiovascular examination reveals a normal S1, S2 with no murmurs appreciated.
Respirations are equal bilaterally without any abnormal breath sounds. Extremities show
no clubbing, cyanosis, or edema. Strength is equal bilaterally and sensation is full
throughout. The patient exhibits normal reflexes. She returns to the clinic several more
times and her blood pressure remains elevated. The most appropriate initial
pharmacotherapy for this patient is
A. amlodipine
B. atenolol
C. enalapril
D. furosemide
E. hydrochlorothiazide
Explanation:
The correct answer is C. This patient is a type I diabetic with mild hypertension. The
Joint National Committee recommends ACE inhibitors, such as enalapril, as first-line
treatment of hypertension in diabetics. Multiple studies have proven that ACE inhibitors
prevent microalbuminuria and thus preserve renal function.
Amlodipine (choice A) is a calcium channel blocker commonly prescribed for
hypertension. However, it has not been proven to have the renal protective properties of
ACE inhibitors. Therefore, choosing amlodipine is incorrect.
Atenolol (choice B) is a beta-blocker that is often used as a first-line agent in nondiabetics. However, beta-blockers should be avoided in patients with type I diabetes,
asthma, and depression. Additionally, the patient's low heart rate would contraindicate
the use of a beta-blocker.
Furosemide (choice D) and hydrochlorothiazide (choice E), a thiazide diuretic and a
loop diuretic, are often used as initial agents in the treatment of hypertension due to
their efficacy and cost effectiveness. However, the renal protective benefits of an ACE
inhibitor make enalapril a more appropriate choice for this patient.
A 37-year-old accountant is hospitalized for a laparoscopic
cholecystectomy. The day after his surgery, he reports feeling palpitations
in his chest. He says that even prior to his hospitalization he had been
feeling nervous and has noticed himself perspiring more easily. His past
medical history is significant for a resection of a benign brain tumor during
childhood. He also mentions that he may have lost weight, although he has
not been dieting. Physical examination reveals a thin, anxious appearing
male. His lungs are clear and cardiac auscultation demonstrates an
irregularly irregular rhythm and no murmurs. Neurologic examination is
significant for a fine tremor in both hands. An electrocardiogram performed
at the bedside shows atrial fibrillation. The most appropriate study at this
time to evaluate this patient's symptoms is
2
A. a chest x-ray
B. a CT scan of the head
C. an exercise tolerance test
D. a serum thyroid stimulating hormone
E. a ventilation/perfusion scan
Explanation:
The correct answer is D. Nervousness, tremor, heat intolerance, and
weight loss are classic signs and symptoms of hyperthyroidism.
Hyperthyroidism is a well known cause of atrial fibrillation. This arrhythmia
will respond to the treatment of the underlying endocrine abnormality. A
serum thyroid stimulating hormone (TSH) level will be abnormally low in
patients with hyperthyroidism and is a very specific test for this disorder.
A chest x-ray (choice A) is not a useful study in the evaluation of atrial
fibrillation in the setting of hyperthyroidism. There is no reason to suspect
other primary lung diseases in an otherwise healthy young male to warrant
a chest x-ray.
A CT of the head (choice B) will not provide information about the etiology
of the patient's atrial fibrillation. He has a distant history of surgical
resection of a benign brain tumor and there is no reason to suspect
metastatic disease. There is no association between primary brain
pathology and atrial fibrillation.
An exercise tolerance test (choice C) is an examination to evaluate for
cardiac ischemia or past infarct. This study is performed by having a
patient exercise on a treadmill while wearing the electrocardiogram leads.
A continuous EKG is performed during exercise to monitor for signs of
ischemia. Cardiac ischemia is a very common cause of atrial fibrillation.
However, there is no reason to suspect an ischemic etiology of this
arrhythmia in a young, otherwise healthy patient.
A ventilation/perfusion scan (choice E) is a good diagnostic study for the
evaluation of a pulmonary embolism. A pulmonary embolism is a known
cause of atrial fibrillation. Although recent surgery and hospitalization does
put the patient at increased risk for thromboembolic disease, he does not
have shortness of breath, chest pain, or other classic symptoms of a
pulmonary embolism. Young and healthy patients do develop
thromboembolic disease in the setting of pelvic and lower extremity
trauma, and prolonged hospitalization or bedrest.
A 20-year-old college student is brought to the emergency department by his
girlfriend because of the sudden onset of a headache, shaking, sweating, and
blurry vision. She says that he became very confused during the taxicab ride
over to the hospital, asking, "where are you taking me to, the airport?" He
3
was fully aware that they were going to the hospital as they left their
apartment 5 minutes earlier. These symptoms started as they were lying in
bed going to sleep, 3 hours after coming back from the local Italian
restaurant, where they both ate fettucine alfredo. They did not drink any
alcohol tonight. He has had similar, but milder, symptoms on four previous
occasions in the past few years. He has no other medical conditions and
does not take any medications. His temperature is 37.0 C (98.6 F), blood
pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 22/min. He
is not oriented to person, place, or time. He begins to lose consciousness
during the physical examination, which is otherwise unremarkable. At this
time the most appropriate conclusion is:
A. He should drink a glass of orange juice immediately
B. An intravenous bolus of glucose as a 50 % solution should be given
immediately
C. An intravenous bolus of isotonic saline should be given immediately
D. Naloxone, given intravenously every 2 minutes, will reverse this
patient's symptoms
E. Physostigmine, given intravenously over 2 minutes, will reverse this
patient's symptoms
Explanation:
The correct answer is B. This patient is most likely experiencing the
symptoms of hypoglycemia, which should be treated with intravenous
glucose until the patient can eat a meal. There are two categories of
symptoms associated with hypoglycemia: the autonomic response and the
neuroglycopenic response. The former is due to excessive secretion of
epinephrine/norepinephrine and consists of tremor, palpitations, sweating,
hunger, and anxiety. The latter is caused by central nervous system
dysfunction and includes dizziness, headache, blurry vision, confusion,
abnormal behavior, and a loss of consciousness. Symptoms do not usually
occur until the blood glucose falls below 45 mg/dL. Causes of hypoglycemia
include postprandial hypoglycemia, fasting hypoglycemia, insulinomas, and
factitious hypoglycemia.
This patient should not have a glass of orange juice (choice A) right now
because he is losing consciousness and therefore cannot eat or drink. The
initial treatment for hypoglycemia with both autonomic and neuroglycopenic
symptoms is intravenous glucose. This can be discontinued when the
patient is able to eat and drink.
Administration of isotonic saline, intravenously (choice C) is part of the initial
treatment for diabetic ketoacidosis. 5% glucose solutions should be added
when the plasma glucose level falls below 300 mg/dL. This would be
inappropriate for a hypoglycemic because they need glucose. The
symptoms of DKA include increased urination, thirst, abdominal pain, mental
status changes, anorexia, nausea, and vomiting. The patient in this case
does not have these symptoms.
4
Naloxone would reverse this patient's symptoms (choice D) if they were
caused by an opioid overdose, not hypoglycemia. Naloxone is an opioid
antagonist that competes for the opioid receptors and will block the effects of
heroin and other opioids. Symptoms of an opioid overdose include miosis,
respiratory depression, coma, hypotension, and bradycardia. The patient in
this case does not have these symptoms.
Physostigmine would reverse this patient's symptoms (choice E) if they were
caused by anticholinergic poisoning, not hypoglycemia. The symptoms of
anticholinergic poisoning can occur with overdoses of antihistamines,
atropine, tricyclic antidepressants, and scopolamine, and include
hyperthermia, vasodilatation, decreased salivation, mydriasis, delirium, and
hallucinations. The girlfriend did not say that he took any medications. The
fact that these symptoms occurred a few hours after a meal and that he has
had similar episodes in the past and his physical examination did not reveal
mydriasis or hyperthermia makes his condition more consistent with
hypoglycemia than anticholinergic poisoning.
A 29-year-old woman comes to the office because of a 12-pound weight gain
in the past 3 months. She does not seem to think that it is related to a change
in appetite. She has no chronic medical conditions and takes no medications.
She exercises regularly and drinks a glass of wine with dinner each night.
She says that she usually only eats foods that are labeled "low-fat" or "fat
free." She has recently moved to your town to live with her fiancee and just
started working as a kindergarten teacher. She enjoys her job and is very
happy in her new home and with her fiancee. She is 168 cm (5 ft 6 in) tall and
weighs 67 kg (148 lb). Her blood pressure is 135/90 mm Hg, pulse is 70/min,
and respirations are 14/min. Physical examination is unremarkable. She is
picking her cuticles and tapping her feet during the history and examination.
The most appropriate next step is to
A. ask her if she recently quit smoking
B. determine thyroid stimulating hormone levels
C. order a biochemical profile
D. order a dexamethasone suppression test
E. refer her to a nutritionist
Explanation:
The correct answer is A. In the evaluation of weight gain, the first step is to
perform a thorough history and physical examination. If the patient tells you
that they have not really had a change in appetite and have had a recent
weight gain, you need to ask about medications, such as tricyclics, steroids,
and antipsychotics and about smoking cessation and psychiatric disorders.
This patient appears fidgety, which may be consistent with smoking
cessation. Smoking cessation is often associated with a small weight gain
(5-10 lbs), but it can lead to more dramatic weight gain in others. Before you
5
perform any expensive and unnecessary diagnostic studies, you should first
perform a detailed history.
Determining thyroid stimulating hormone levels (choice B) is appropriate in
the evaluation of weight gain if there is a negative drug history, no recent
smoking cessation, and a normal biochemical profile. Since hypothyroidism
is part of the differential diagnosis for weight gain, you should consider it
early in the work-up, but a biochemical profile should be performed first.
The initial work-up for weight gain is a detailed history, including medication
and drug use and recent smoking cessation. If those are negative, then a
biochemical profile (choice C) is indicated. A biochemical profile may
indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes
will most likely lead to an elevated glucose, while Cushings is sometimes
associated with hypokalemia, hypochloremia, metabolic alkalosis,
hyperglycemia, and hypercholesterolemia.
A dexamethasone suppression test (choice D) is part of the initial evaluation
of Cushing syndrome. You should first perform a complete history and if
negative for such things as drug history, recent smoking cessation, and a
psychiatric disorder, you should then order a biochemical profile. A
dexamethasone suppression test should be ordered if the biochemical
profile is suspicious for Cushing syndrome (hypokalemia, hypochloremia,
metabolic alkalosis, hypercholesterolemia, and hyperglycemia).
Referring her to a nutritionist (choice E) is inappropriate at this time. The
case says that the patient has had weight gain with no change in appetite or
eating habits. She requires a thorough history and examination, and if
negative, an evaluation for a medical condition such as Cushing syndrome,
diabetes mellitus, thyroid disease (even though this is usually associated
with a poor appetite), and fluid overload. A nutritionist may be valuable later
if the complete evaluation is negative and you determine that she has poor
eating habits. Obviously in that case you should try to help her with her
dietary habits, but if you are unsuccessful, a nutritionist may be helpful.
A 44-year-old obese woman comes to the clinic for a routine follow up visit for
diabetes. Her diabetes has been poorly controlled in the past year and her
hemoglobin A1c level was last at 11%. She denies any new problems with
her health. On physical examination, you note firm, non-pitting induration on
her upper back with a clear cut-off border. Within the indurated areas there
are small papules resembling follicular prominences. Under her breasts are
beefy-red patches in the moist areas with satellite lesions. On her left pretibial
area, there is a dusky-red elevated plaque with a sharply circumscribed
border. There is an orange-hue to this lesion, and the center of the lesion is
flattened and atrophic. In the order of these descriptions, the cutaneous
manifestations of diabetes that this patient has are
A. scleredema, candidiasis, necrobiosis lipoidal diabeticorum
B. scleredema, candidiasis, stasis dermatitis
6
C. scleredema, tinea corporis, stasis dermatitis
D. scleroderma, candidiasis, necrobiosis lipoidal diabeticorum
E. scleroderma, tinea corporis, stasis dermatitis
Explanation:
The correct answer is A. Scleredema, candidiasis, necrobiosis lipoidal
diabeticorum (NLD) is correct, because these three are all commonly
associated with diabetes. Scleredema is a connective disorder with sudden
onset of marked, nonpitting, symmetric induration of the posterior and lateral
aspects of the neck spreading to shoulders, upper back, and proximal arms.
The indurations are of wood-like consistency. Erythematous papular
eruption occurs during the early stage of the disease. A syndrome has been
recognized consisting of scleredema of long duration, obesity, maturity
onset, latent or overt diabetes, and high incidence of cardiovascular disease.
Candida albicans flourishes in the recesses created by redundant skin folds.
Exacerbating factors may include diabetes mellitus, systemic medications,
nutritional factors, and diminished salivary function. NLD is relatively
asymptomatic, and is characteristically found on the anterior and lateral
lower legs. They may also be present on the face, arms, and trunk. They
begin as small, red nodules that enlarge to a plaque with irregular, flattened
and eventually depressed atrophy. NLD seems to be a marker for diabetes.
Stasis dermatitis (choice B) is incorrect because classical stasis dermatitis
appears on the medial surface of lower extremities with hyperpigmented
patches mixed with occasional erythematous plaques. Often times, one can
appreciate tortuous enlarged varicose veins.
Tinea corporis (choice C) is incorrect because it generally presents with
erythematous annular plaques, with central clearing and no satellite lesions.
Scleroderma (choice D) and (choice E) is incorrect, because this is a
connective disorder associated with the tightening of the skin, difficulty
swallowing, telangiectasia, calcinosis, sclerodactyly, and other systemic
involvement.
An 83-year-old woman with a history of hypertension and osteoarthritis comes to the
office because of abdominal pain with occasional nausea, constipation, muscle
weakness, and fatigue over the last 4 months. She denies taking any over-the-counter
medications or vitamins. She denies weight changes, change in stool diameter, melena,
bright red blood per rectum, or shortness of breath. You notice in her chart that she had
a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure
is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is
normal except for mild kyphosis. Her rectal examination is heme negative. Laboratory
studies show:
7
The most appropriate next step is to
A. determine parathyroid hormone levels
B. determine serum vitamin D levels
C. determine thyroid stimulating hormone levels
D. order a CT scan of the neck
E. order a serum protein electrophoresis
Explanation:
The correct answer is A. This patient has symptomatic hypercalcemia. The most likely
etiology in this patient is hyperparathyroidism. This diagnosis is made by checking PTH
levels. Since her calcium is elevated, a normal or high PTH level is inappropriate and
therefore would help confirm the diagnosis.
Vitamin D (choice B) intoxication is typically secondary to patients taking large amounts
of vitamin D (often for treatment of hypoparathyroidism). The treatment is to discontinue
vitamin supplementation and recheck levels. This patient denied taking over-thecounter medications or vitamins.
Ordering a TSH (choice C) is never a bad idea in a patient with a variety of vague
complaints since thyroid disease is very common and because it can explain these
symptoms. In this patient, you would expect to find hypothyroidism based on her
symptoms but an elevated serum calcium is more likely explained by hyperthyroidism
secondary to increased bone turnover. Therefore, a PTH level would more likely lead to
the correct diagnosis.
CT scanning of the neck (choice D) is very sensitive for parathyroid disease but it is not
meant to be used as a screening test for hyperparathyroidism. Rather, the diagnosis is
made by checking serum calcium and PTH levels.
Multiple myeloma is a common disease and can cause hypercalcemia as well. A serum
protein electrophoresis (choice E) is helpful in making this diagnosis by demonstrating a
monoclonal spike in the beta or gamma globulin region. Our patient lacks anemia, renal
disease, or significant back pain which makes multiple myeloma less likely.
8
A 68-year-old woman is admitted to the hospital because of lethargy and dehydration.
She lives alone and has had regular checkups in the office. Her past medical history is
significant for diabetes mellitus, which is controlled with diet and oral antidiabetic agents.
She has a history of mild systolic hypertension, treated with a thiazide diuretic. Her last
visit to your office was 3 months ago, at which time she was started on digoxin for
control of heart rate. Since then, she has been taking digoxin and the diuretics without
fail with good control of her heart rate and no evidence of heart failure. On admission,
she is lethargic, but can be easily aroused. Her skin and mucous membranes are dry.
Her temperature is 37.8 C (100.0 F), blood pressure is 110/70 mm Hg, and pulse is
90/min. Examination of the chest, abdomen, and extremities is normal. An
electrocardiogram shows atrial fibrillation. Her laboratory studies show:
Urine analysis shows red cells, white cells, and few bacteria without any protein. An
abdominal radiograph reveals a small, calcified density in the region of the right kidney.
The most likely cause for this patient's metabolic abnormality is
A. hyperparathyroidism
B. hyperthyroidism
C. metastatic malignancy
D. multiple myeloma
E. thiazide diuretic overdose
Explanation:
The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating
bone resorption. Serum calcium levels normalize when the patient becomes euthyroid.
Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid
hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise
suspicion for hyperthyroidism and should be investigated further.
Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and
parathyroid hormone levels, normal or elevated urine calcium excretions, and low or
normal plasma concentration of phosphates.
9
Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with
solid tumors, including lung carcinoma, breast carcinoma, and squamous cell
carcinoma of the head and neck. The hypercalcemia is thought to be caused by
parathyroid hormone related protein secreted by the tumor. Patients with hematological
malignancies may also have increased serum calcium levels, but this is thought to be
due to cytokines causing increased osteoclastic activity in the bone.
Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine
analysis shows protein in urine in multiple myeloma patients.
Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum
phosphate would likely be depressed. In this patient, although the calcium levels are
elevated, the phosphorus levels are high normal.
A 68-year-old woman is admitted to the hospital because of lethargy and
dehydration. She lives alone and has had regular checkups in the office. Her
past medical history is significant for diabetes mellitus, which is controlled
with diet and oral antidiabetic agents. She has a history of mild systolic
hypertension, treated with a thiazide diuretic. Her last visit to your office was
3 months ago, at which time she was started on digoxin for control of heart
rate. Since then, she has been taking digoxin and the diuretics without fail
with good control of her heart rate and no evidence of heart failure. On
admission, she is lethargic, but can be easily aroused. Her skin and mucous
membranes are dry. Her temperature is 37.8 C (100.0 F), blood pressure is
110/70 mm Hg, and pulse is 90/min. Examination of the chest, abdomen, and
extremities is normal. An electrocardiogram shows atrial fibrillation. Her
laboratory studies show:
Urine analysis shows red cells, white cells, and few bacteria without any
protein. An abdominal radiograph reveals a small, calcified density in the
region of the right kidney. The most likely cause for this patient's metabolic
abnormality is
A. hyperparathyroidism
B. hyperthyroidism
10
C. metastatic malignancy
D. multiple myeloma
E. thiazide diuretic overdose
Explanation:
The correct answer is B. Hyperthyroidism may cause increased calcium by
stimulating bone resorption. Serum calcium levels normalize when the
patient becomes euthyroid. Patients with hyperthyroidism do have cardiac
effects from increased levels of thyroid hormone. Recent onset of atrial
fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism
and should be investigated further.
Patients with hyperparathyroidism (choice A) typically have elevated serum
calcium and parathyroid hormone levels, normal or elevated urine calcium
excretions, and low or normal plasma concentration of phosphates.
Hypercalcemia of malignancy (choice C) is usually very high and seen in
patients with solid tumors, including lung carcinoma, breast carcinoma, and
squamous cell carcinoma of the head and neck. The hypercalcemia is
thought to be caused by parathyroid hormone related protein secreted by
the tumor. Patients with hematological malignancies may also have
increased serum calcium levels, but this is thought to be due to cytokines
causing increased osteoclastic activity in the bone.
Multiple myeloma (choice D) causes hypercalcemia by increased cellular
lysis. Urine analysis shows protein in urine in multiple myeloma patients.
Thiazide diuretic overdose, (choice E) may increase serum calcium levels,
but serum phosphate would likely be depressed. In this patient, although the
calcium levels are elevated, the phosphorus levels are high normal.
A 70-year-old man with hypertension, hyperlipidemia, and chronic atrial
fibrillation is brought to the emergency department for confusion. He was
recently diagnosed with multiple myeloma. His medications include
furosemide, captopril, atorvostatin, digoxin, and warfarin. He is allergic to
penicillin to which he gets a rash. His temperature is 37.0 C (98.6 F), blood
pressure is 100/60 mmHg, pulse is 98/min, and respirations are 23/min.
Physical examination shows an irregular cardiac rhythm and a soft systolic
murmur at his cardiac base. An electrocardiogram shows atrial fibrillation.
Laboratory studies show:
Sodium
143 mEq/L
Potassium 4.5 mEq/L
Chloride
104 mEq/L
Bicarbonate 26 mEq/L
Calcium
13 mg/dL
Glucose
109 mg/dL
11
The most appropriate next step is management is to
A. administer albumin, intravenously
B. administer a dextrose bolus followed by insulin, intravenously
C. administer magnesium sulfate, intravenously
D. administer pamidronate, intravenously
E. hydrate him with normal saline and then administer furosemide,
intravenously
Explanation:
The correct answer is E. The most appropriate acute treatment of
hypercalcemia is hydration followed by a forced diuresis. It is important to
hydrate patients prior to administering the diuretic since most patients with
this condition are hypovolemic from hypercalcemia induced nausea/vomiting
and diabetes insipitus.
Administration of albumin (choice A), albeit a binder of serum calcium, has
no role in the management of hypercalcemia.
Administration of dextrose followed by insulin (choice B) is one of the
treatments of choice for acute hyperkalemia. It has no role in the
management of hypercalcemia.
Administration of magnesium sulfate (choice C) has no role in the
management of hypercalcemia.
Administration of pamidronate (choice D), a bisphosphonate which can
decrease bone resorption, can be used in the chronic management of
hypercalcemia, but has no role in its acute management.
An 18-year-old man with type I diabetes mellitus is brought to the emergency
department by a friend after being found comatose. There is a known history
of noncompliance with medications, however, there is no known history of
drug use. Vital signs are: temperature 37 C (98.6 F), blood pressure 80/65
mm Hg, pulse 110/min, and respirations 17/min. Oxygen saturation obtained
while the patient is receiving supplemental oxygen of 2 L/min via nasal
cannula is 98%. The patient is comatose and is taking rapid, shallow breaths.
Deep tendon reflexes are hypoactive. An intravenous line has been placed in
the field. A fingerstick glucose is 430 mg/dL. An arterial blood gas, basic
chemistry panel, and toxicology screen has been sent to the laboratory. The
next step in the management of this patient is
A. a chest x-ray
B. an endotracheal intubation
C. an intravenous fluid replacement with insulin
12
D. methadone
E. a pulmonary artery catheter insertion
Explanation:
The correct answer is C. This patient is suffering from diabetic ketoacidosis
(DKA) caused by a severe deficiency of insulin. Clinical symptoms include
coma, rapid and shallow breathing, high serum glucose levels, and
metabolic acidosis. The immediate management of this patient includes
intravenous fluid replacement and insulin infusion. When laboratory results
return, electrolyte imbalances must also be corrected.
A chest x-ray (choice A) would be complementary to a complete the
evaluation of any comatose patient. In this patient with a picture of diabetic
ketoacidosis, a chest x-ray would be a secondary concern. The first priority
is intravenous fluid replacement and insulin therapy.
Endotracheal intubation (choice B) is not necessary at this point as the
patient has a normal oxygen saturation. Adequacy of respiration will need to
be reassessed when the arterial blood gas results are available. The first
priority is intravenous fluid replacement and insulin therapy.
Methadone (choice D) is used to treat heroin dependency.
A pulmonary artery catheter (choice E) is not yet necessary as the patient is
at the present time hemodynamically stable. The first priority is intravenous
fluid replacement and insulin therapy.
A 45-year-old man comes to the clinic for a follow-up visit for hypercholesterolemia. On
the previous visit, you placed him on a diet to lower his cholesterol. Now he tells you that
he was following the diet, although he does not like it. At the same time he expresses
concern that because his father died of a heart attack, dietary changes might not be
sufficient for him. He hands you an article that he downloaded from the Internet extolling
the virtues of a new cholesterol-lowering drug. You promise to look at the article and tell
the patient what you think about it during his next visit in 3 months. The article describes
a double-blind clinical trial in which patients with cholesterol levels over 240 were
assigned to 1 of 3 groups: diet change only, drug only, or diet change and drug
combined. Patients were followed over a 6-month period, and changes in cholesterol
level from baseline was computed. The results of the study are presented in the table
below.
13
The drug was also shown to have significant side effects in 10% of the patients taking the
drug. Based on this article, your recommendation to the patient should be
A. because there is no difference between the effects of dietary change or taking
the drug, the patient can choose which one he prefers
B. diet alone is sufficient and adding the drug will not provide enough clinical
advantage to warrant the risk of the side effects
C. studies found on the Internet are not a good source of information for making
treatment decisions
D. taking the drug by itself has sufficient clinical merit, so that dietary change is
not required
E. taking the drug either with or without dietary change has sufficient clinical effect
to merit giving the patient a prescription
F. the drug should be taken, but only in conjunction with dietary change
G. the results of this study may not apply to this patient and a 3-month trial
dosage of the drug should be given to see what effect it has
Explanation:
The correct answer is B. All three conditions show a lowering of cholesterol levels and
the p-values indicate statistically significant differences among all three groups.
However, the magnitude of the differences among the groups means that these
differences are not clinically significant. Changes of 1 or 2 points in cholesterol levels
are unlikely to be clinically meaningful. Because dietary change provides a notable
lowering of cholesterol levels and avoids the possible side effects of the drug, this is the
therapeutic option that gives the best benefit/risk ratio. Note that, of course, the
physician should discuss with the patient his concerns that diet alone is not sufficient
and explain the reasoning for this decision in detail.
Because there is no difference between the effects of dietary change or taking the drug,
the patient can choose which one he prefers (choice A), taking the drug by itself has
sufficient clinical merit, so that dietary change is not required (choice D), taking the drug
either with or without dietary change has sufficient clinical effect to merit giving the
patient a prescription (choice E), and the drug should be taken, but only in conjunction
with dietary change (choice F) are all incorrect because the three groups are statistically
significant; however, not clinically significant.
14
Studies found on the Internet are not a good source of information for making treatment
decisions (choice C) is incorrect, because although everything on the Internet cannot be
taken at face value, there are a number of excellent sites that publish valid, important
medical information. The fact that the article was from the Internet, by itself, does not
invalidate the article as a source of information.
The results of this study may not apply to this patient and a 3-month trial dosage of the
drug should be given to see what effect it has (choice G) is incorrect, because although
the patient may have particularities which make the effects on him different than the
published study, the study results should be taken as accurate, unless and until an
individual patient's experience proves differently. Otherwise, all research would be
useless and every drug would have to be tested on every patient.
A 47-year-old woman comes to the office with newly diagnosed type 2 diabetes mellitus
for a follow-up visit regarding laboratory studies that you had ordered. She has no
complaints at this time. Her temperature 37 C (98.6 F), blood pressure is 122/80 mm Hg,
pulse is 82/min, and weight is 116 kg (255 lb). Visual acuity is 20/20 in both eyes. Her
hemoglobin A1C is 6.0% and her fasting blood glucose is 132 mg/dL. During your
discussion with her, she relates that her father had diabetes and "went blind." She asks
you if she should go to an ophthalmologist. The most appropriate response is:
A. "Good visual acuity is an accurate predictor of the absence of diabetic
retinopathy."
B. "I will perform yearly funduscopic exams and will refer you for ophthalmology
consultation at the first sign of diabetic retinopathy."
C. "Ophthalmology consultation is recommended 5 years after the diagnosis of
diabetes and yearly thereafter."
D. "With well-controlled diabetes you will prevent diabetic visual complications
making a visit to an ophthalmologist unnecessary at this point."
E. "Yearly ophthalmology appointments should begin now."
Explanation:
The correct answer is E. Yearly eye exams by an ophthalmologist are recommended for
all patients with type 2 diabetes mellitus beginning at the time of diagnosis.
Good visual acuity is not a predictor of the presence or absence of diabetic retinopathy
(choice A).
Funduscopic exams (choice B) should be a part of a primary care physician's
evaluation of a patient with diabetes mellitus; however, the standard of care for
diagnosis and treatment of diabetic retinopathy is under the care of an ophthalmologist.
Young patients who are newly diagnosed with type 1 diabetes may delay
ophthalmology consultation for 5 years in the absence of visual complaints, but this
does not apply to type 2 patients (choice C).
Good control of diabetes is important in preventing diabetic retinopathy; however, some
patients will have diabetic retinopathy despite excellent control (choice D). Furthermore,
15
diabetic patients are more likely to have other ocular diagnoses such as cataracts and
glaucoma that are more easily diagnosed and managed by an ophthalmologist.
You are caring for a patient in the intensive care unit who was admitted 2
hours earlier with diabetic ketoacidosis. She is a 19-year-old girl with no
known medical problems prior to this admission when her parents brought
her in with abdominal pain, nausea, vomiting, and mild confusion. On
admission her laboratory results were as follows:
Sodium
129 mEq/dL
Potassium
5.5 mEq/dL
Chloride
88 mEq/dL
Bicarbonate
12 mEq/dL
Urea nitrogen, serum 51 mg/dL
Creatinine
2.0 mg/dL
Glucose
697 mg/dL
An insulin drip was started at 11 U/hr and intravenous fluids were started at
250 cc/hr. Two hours later, laboratory studies show:
Sodium
132 mEq/dL
Potassium
4.0 mEq/dL
Chloride
89 mEq/dL
Bicarbonate
13 mEq/dL
Urea nitrogen, serum 41 mg/dL
Creatinine
1.9 mg/dL
Glucose
277 mg/dL
Shortly after these laboratory results return, the patient becomes
unresponsive. Papilledema is observed bilaterally. The most likely
explanation for the patient's rapid deterioration is
A. arterial thrombosis associated with diabetic ketoacidosis
B. overlooking of toxic screen in patients initial evaluation
C. rapid lowering of serum glucose
D. use of a relatively hypertonic solution for rehydration
E. worsening lactic acidosis and tissue ischemia
Explanation:
The correct answer is C. The target for lowering serum glucose is
approximately 50-100 mg/dL/hour. More aggressive lowering of the serum
glucose can result in cerebral edema. This is because the CSF glucose
decreases more slowly than the serum glucose. If the serum glucose is
lowered too rapidly, the CSF fluid is relatively hypertonic compared to the
16
serum. Therefore, water will enter the CSF creating edema.
Arterial thrombosis (choice A) occurs with increased frequency in DKA. This
can manifest as MI, ischemic limbs, or stoke. The fact that this patient has
papilledema suggests that edema is more likely than stroke. This patient's
age also makes stroke less likely.
Toxic screening for drugs should be part of the initial evaluation of a patient
with altered mental status. This patient has an anion gap acidosis with an
elevated glucose and likely does have DKA. Therefore, a toxic drug screen
(choice B) is not the best answer.
Normal saline (choice D) is an appropriate solution for rehydration in this
patient. Although the patient's sodium is 129 mEq/dl on admission, when
corrected for the elevated glucose, the sodium is 139 mEq/dL. Remember
that these patients are very dehydrated on admission and need to be
volume resuscitated.
Lactic acidosis (choice E) can occur in patients with DKA from prolonged
dehydration, infection, or tissue hypoxia. One would suspect that if this
patient had a lactic acidosis on admission that it would correct with proper
DKA management. You would not expect brain herniation from lactic
acidosis.
A 45-year-old woman returns to your office to discuss the results of "blood tests" drawn
3 days earlier when she was complaining of fatigue, weight loss, frequent urination,
and blurred vision for the last several weeks. She is a non-smoker and drinks 1 glass
of wine per week. She had no past medical or surgical history and a complete physical
examination 3 days earlier was unremarkable including a blood pressure of 130/72 mm
Hg. Laboratory studies show:
17
Based on these studies, you decide to begin treatment with rosiglitazone. At this time,
the most important additional study to perform is
A. alanine aminotransferase and aspartate aminotransferase
B. electrocardiogram
C. free thyroxine and T3 reuptake
D. 1-hour glucose tolerance test
E. 24 hour urine protein collection
Explanation:
The correct answer is A. This patient has type II (adult-onset) diabetes, which has
been diagnosed by a fasting glucose over 200 mg/dl and classic symptoms, including
weight loss, blurred vision, and polyuria. The class of drugs known as
thiazolidinediones, which includes rosiglitazone (Avandia) and pioglitazone (Actos) are
often used as initial monotherapy. The mechanism of action is through enhancing
insulin sensitivity of peripheral tissues. However, these medications have been shown
to cause liver toxicity. Therefore, it is recommended to check liver enzymes before
initiating therapy and every other month for the first year of therapy.
EKG (choice B) is not indicated as she has no cardiac complaints, no cardiac history,
and is normotensive.
Given her complaints of fatigue and weight loss, a thyroid disorder was a possibility in
your workup. However, given her normal TSH, further thyroid studies (choice C) are
not necessary at this time.
1-hour glucose tolerance test(choice D), is no longer used as a method for diagnosing
diabetes except as a screening test during pregnancy. The patient's fasting glucose of
206, along with her classic symptoms are enough to make the diagnosis.
It is important to screen all diabetic patients for renal disease. Though screening for
microalbuminuria is indicated, it is best performed by a spot urine
microalbumin/creatinine ratio, instead of a 24 hour urine test(choice E).
A 52-year-old man comes to the clinic because he has been feeling weak and
dizzy for the past several days. He also tells you that at the same time he
feels somewhat restless and has had a mild headache. His past medical
history is significant only for some mild chronic low back pain for which he
occasionally takes acetaminophen. His temperature is 37.0 C (98.6 F), blood
pressure is 128/78 mm Hg, pulse is 78/min, and respirations are 18/min.
Physical examination shows diffuse hyporeflexia and scant basilar crackles in
the lungs. Laboratory studies show a leukocyte count of 8,900mm3,
hematocrit 40%, platelets 295,000mm3, sodium 126 mEq/L, potassium 3.8
mEq/L, bicarbonate 18 mEq/L, blood urea nitrogen 9 mg/dL, creatinine 0.6
mg/dL, glucose 115 mg/dL, serum osmolality is 258 mOsm/kg (normal 280),
and urine osmalality is 150 mmol/L. A chest x-ray shows a 4-centimeter right
upper lobe mass and mediastinal adenopathy. The most appropriate next
18
step in management is to
A. admit the patient to the hospital and start an infusion of hypertonic
(3%) saline until serum sodium normalizes
B. prescribe demeclocycline 150 mg orally 4 times per day, then follow
up in 2 weeks with an oncologist
C. refer the patient to cardiothoracic surgery for a lung biopsy
D. restrict the patient to 1500 mL of water per day and obtain CT scan
of the chest
E. schedule the patient for the next available oncology appointment
Explanation:
The correct answer is D. This patient is presenting with a classic syndrome
of inappropriate antidiuretic hormone secretion (SIADH). He has
hyponatremia with elevated urine osmolality in the presence of decreased
serum osmolality. The clinical symptoms are often vague like his, until more
serious seizures or coma present. One of the most common causes of
SIADH is small cell cancer of the lung, which he most likely has. The
mainstay of treatment is with fluid restriction once the serum sodium level is
greater than 125 mEq/L. If the patient's initial sodium is less than 125
mEq/L, then treatment with 0.9% normal saline or possibly even more
hypertonic solutions (choice A) may be necessary. It is important not to
correct the sodium level too quickly or a deadly syndrome known as central
pontine myelinolysis may result. The actual appropriate rate is controversial.
However, some recommend a rate of less than 0.5 mmol/L/hr. A CT scan of
the chest will also be helpful to both the surgeon and oncologist.
Demeclocycline is a medication that actually has nephrogenic diabetes
insipidus (the opposite of SIADH) as one of its side effects by blocking the
action of antidiuretic hormone. This medication is often adjunctive in the
treatment of SIADH. However, you would not simply want to follow up with
the patient in 2 weeks (choice B). They need much more vigilant care, as
further hyponatremia can result in severe neurologic sequellae.
Similarly, a lung biopsy (choice C) and a referral to an oncologist (choice E)
will certainly be eventually required in this patient. However, treating the
hyponatremia is of prime importance.
A 57-year-old woman comes to your office because she is frustrated about the control of
her diabetes. She insists that she has been compliant with her diet but her sugars
continue to be poorly controlled. Her current insulin regimen is as follows:
14 units NPH and 6 units regular insulin 30 minutes prior to breakfast, 8 units regular
insulin 30 minutes prior to dinner, and 10 units NPH insulin before bedtime
She has brought along a log of her sugars.
DAY
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
19
8a.m.** 230*
11a.m. 133
4p.m. 99
9p.m. 300
188
120
103
198
195
100
129
145
197
179
113
139
210
122
147
306
150
120
133
167
306
111
89
203
*Numbers reflect glucose in mg/dl
**8 a.m. sugars are fasting. The most appropriate changes to this patient's insulin
regimen would include
A. decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH
insulin
B. increasing bedtime NPH insulin and increasing dose of pre-dinner regular
insulin
C. increasing NPH insulin and regular insulin doses prior to breakfast
D. increasing pre-breakfast regular insulin and increasing pre-dinner regular
insulin
E. increasing pre-dinner regular insulin dose only
Explanation:
The correct answer is B. This patient has blood sugars which are poorly controlled in
the morning and at 9 p.m. Fasting sugars are a reflection of night time NPH doses while
late morning sugars are a reflection of a.m. regular doses. Evening sugars reflect dinner
time regular insulin. The approximate onset of action, peak effect, and duration of action
of NPH insulin and regular insulin are shown below:
Type Insulin Duration of action Onset of Action (hr) Peak Effect Peak Effect
Regular
0.5-1
2-4
4-6
NPH
2-4
8-14
16-24
Decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH insulin
(choice A) would increase 11 a.m. sugars and decrease 4 p.m. sugars.
Increasing NPH insulin and regular insulin doses prior to breakfast (choice C) would be
reflected in 11 a.m. and 4 p.m. sugars respectively.
Increasing pre-breakfast regular insulin and increasing pre-dinner regular insulin
(choice D) would be reflected in 11 a.m. and 9 p.m. sugars respectively.
Increasing pre-dinner regular insulin dose only (choice E) would reduce 9 p.m. sugars
only.
This question might seem confusing, but when confronted with a question that requires
that you adjust a patient's insulin regimen it is helpful to answer the question without
looking at any answer choices. You could then simply match your answer with the
answer choices. Again, remember that a.m. regular insulin will control glucose levels
after breakfast. NPH insulin given in the morning will peak around lunch time and will be
reflected in post-lunch sugars. Pre-dinner regular insulin will obviously help you with
night time or post-dinner sugars and night time NPH will help you control overnight
20
sugars. If you remember this, this question becomes much less overwhelming.
A 60-year-old man with diabetes mellitus, hypertension, hyperlipidemia, and chronic
renal insufficiency is admitted to the hospital because of lightheadedness. His
medications include NPH insulin, amlodipine, and simvastatin. He is allergic to
penicillin to which he gets an angioedema. His temperature is 37.1 C (98.8 F), blood
pressure is 98/65 mm Hg, pulse is 87/min, and his respiratory rate is 22/min. On exam,
he is ill appearing. His cardiac rhythm is regular and breath sounds are clear bilaterally.
His abdominal exam is benign. A chest radiograph shows clear lungs. An
electrocardiogram shows a sinus rhythm with peaked T waves. Laboratory studies
show a serum sodium of 134 mEq/L, glucose of 98 mg/dL, and potassium of 6.2
mEq/L. The most appropriate intervention at this time is
A. administration of glucose, orally
B. administration of insulin and glucose, intravenously
C. administration of furosemide, orally
D. administration of ringers lactate, intravenously
E. administration of sodium chloride, intravenously
Explanation:
The correct answer is B. Hyperkalemia with electrocardiographic changes (peaked T
waves) requires immediate medical treatment to prevent the onset of hyperkalemiainduced dysrhythmias. Administration of insulin intravenously causes serum
potassium to move intracellularly, acutely reducing serum potassium. Glucose is coadministered to prevent insulin-induced hypoglycemia.
Oral glucose (choice A) is of no utility in the treatment of hyperglycemia. Even when
insulin is used for the treatment of hyperkalemia, glucose should be co-administered
intravenously.
Oral furosemide (choice C) is an appropriate choice for the long-term treatment of
hyperkalemia, i.e., once the acute hyperkalemia has been treated. Interventions such
as insulin and glucose simply cause the potassium to shift intracellularly. Its excretion
can then be promoted by administration of diuretic agents such as furosemide.
Ringers lactate (choice D) should be avoided with hyperkalemic patients since it
contains potassium as a constituent (4 mEq/L).
Sodium chloride (choice E) is not useful in the management of hyperkalemia.
A 61-year-old woman with chronic renal insufficiency due to long-standing diabetes
mellitus comes to the office with a fever, cough, shaking chills, and fatigue. She has
long-standing diabetes mellitus with her last hemoglobin A1C being 9.1%, BUN 51
mg/dL, and creatinine 2.1 mg/dL. A chest radiograph demonstrates a right lower lobe
infiltrate. Oral antibiotics are prescribed for the patient. The most correct statement
concerning a diabetic patient with an infectious process is:
21
A. Antimicrobial dosing must be adjusted due to decreased liver function
B. Antimicrobial dosing must be adjusted due to decreased renal function
C. Diabetics have the same epidemiology of pulmonary infections as nondiabetics
D. It is more common for diabetics to have lower lobe pneumonia when
compared to non-diabetics
E. Oral antibiotics are not efficacious for treating pneumonia in diabetics
Explanation:
The correct answer is B. All drugs (substances in general) are eliminated from the body
by means of either renal or hepatic clearance or both. This is one of the most important
concepts known by physicians. Almost every patient that presents to inpatient medical
services today has some impairment of one or both of these mechanisms. This must be
kept in mind when prescribing any drug. In the case of this patient, renal antibiotic
dosing schedules for variable renal function are available to every student and house
officer and should be consulted regularly. This patient has a creatinine of 2.1 mg/dL,
reflecting abnormal renal function.
Antimicrobial dosing must be adjusted due to decreased liver function (choice A),
although true as a general rule, is not particularly relevant to diabetics since their
disease has no impact on liver function. We have no specific evidence that this patient
has impaired hepatic function.
Diabetics have the same epidemiology of pulmonary infections as non-diabetics (choice
C) is incorrect as diabetics are more likely to suffer from Staphylococcus aureus and
fungal pneumonia.
It is more common for diabetics to have lower lobe pneumonia when compared to nondiabetics (choice D) is incorrect. Although certain patient populations tend to have
anatomical variation in the location of their pneumonia, the common relationship
between all of them is that they suffer from some sort of aspiration. Examples include
intubated patients on mechanical ventilation and alcoholics. Diabetics are not included
in this group.
Oral antibiotics are not efficacious for treating pneumonia in diabetics (choice E) is
false. Oral antibiotic efficacy is determined by the causative organism and location of
the infection. Some specific dysfunctions such as gastric achlorhydria or bowel
obstruction may interfere with oral efficacy, but not simply the presence of diabetes.
Being a diabetic may make one prone to more malignant infections. There is no data
that initial treatment of community acquired pneumonia in diabetics should be any
different when compared to non-diabetics.
A 65-year-old woman comes to the clinic for a follow up visit after being diagnosed with
type II diabetes mellitus. She is obese with a history of hypertension, hyperlipidemia, and
osteoarthritis. Despite a 3-month trial of diet and exercise, her weight has increased by 3
pounds. In addition, her hemoglobin A1C has increased from 7.8% to 9.0% and her
fasting blood sugar ranged from 167-188 mg/dL on the glucometer she now uses at
22
home. With the exception of an elevated glucose, her laboratory results are within
normal limits. The most appropriate pharmacotherapy for this patient is
A. Acarbose
B. Chlorpropamide
C. insulin NPH at bedtime
D. insulin 70/30 BID
E. metformin
Explanation:
The correct answer is E. Metformin acts predominately to decrease hepatic glucose
production in the liver. It is an excellent choice for obese patients with diabetes because
it promotes modest weight loss by actually decreasing the amount of insulin necessary
because of decreased glucose produced by the liver. It is an appropriate drug for
monotherapy or combination therapy of diabetes. It should not be used in patients with
renal failure or those patients who are 80 years of older (creatinine clearance
decreases with age) because or the risk of lactic acidosis. When metformin is used
correctly, complications are uncommon. Because the amount of insulin secreted is not
increased, it does not cause hypoglycemia.
Acarbose (choice A) is an alphaglucosidase inhibitor. It works by decreasing the rate of
glucose entry into the blood stream, thereby preventing some of the post prandial
hyperglycemia. Acarbose has been shown to give a slight decrease in hemoglobin A1C
concentrations. In clinical practice, these drugs are poorly tolerated because of
gastrointestinal side effects such as diarrhea, bloating, and gas.
Chlorpropamide (choice B) is a first-generation sulfonylurea. It works (as do all drugs in
the sulfonylurea class) by binding to a receptor on the beta cells of the pancreas and
stimulating insulin secretion. This class of drugs can be used as first-line treatment or
can be used in combination with other medications. Chlorpropamide is rarely used
today because of its propensity to cause more hypoglycemia than newer drugs in the
class.
Patients on multiple medications who continue to have poor glycemic control can be
tried on a bedtime dose of NPH insulin. (choice C). If this is not effective, then twice a
day injections with 70/30 should be added.
Insulin 70/30 (choice D) is typically used only if poor control is achieved with oral
agents. Obviously, most patients would prefer to take medication by mouth rather than
injecting themselves with insulin. An exception to this would be a type II diabetic who
presents with symptoms of hyperglycemia such as weight loss, polyuria or polydipsia.
These patients can be started on insulin as initial therapy.
Above imformation from Clinical Geriatrics "Improving Disease Management with New
Treatments for Type 2 Diabetes Mellitus" Volume 8, number 7, June 2000.
A 63-year-old man comes to the office because of "problems seeing." He
23
says that his wife is making him "get some help" because he got into a minor
car accident last night, and it was his fault because he had difficulty seeing.
His vision is "fine" during the day, but he is basically "blind as a bat" when it is
dark. He admits to an "occasional bottle of vodka." He has dry skin with
multiple, diffuse areas of hyperkeratosis. His condition would most likely have
been prevented by supplementation with
A. niacin
B. vitamin A
C. vitamin B1
D. vitamin B12
E. vitamin C
Explanation:
The correct answer is B. This patient most likely has a vitamin A (retinoic
acid) deficiency, which is characterized by night blindness and dry,
hyperkeratotic skin. It can progress to conjunctival dryness, corneal
ulceration, and necrosis. It occurs in patients with malabsorption or
proteinuria, liver disease, alcoholics, and those receiving total parenteral
nutrition (TPN).
Niacin (choice A) deficiency, which is often called pellagra, is characterized
by diarrhea, dementia, and dermatitis. It occurs in individuals with a high
intake of maize (corn). It is not associated with night blindness.
Vitamin B1 (thiamine) deficiency (choice C), which is often called beri-beri, is
characterized by high output heart failure and central nervous system
disturbances (Wernicke-Korsakoff syndrome). Wernicke-Korsakoff syndrome
occurs in alcoholics and is associated with nystagmus, ataxia, confabulation,
and retrograde amnesia. It is not associated with night blindness.
A deficiency of vitamin B12 (choice D) is associated with megaloblastic
anemia and peripheral neuropathy. It is not associated with night blindness.
It occurs in individuals with pernicious anemia, postgastrectomy, and those
with intestinal organisms or ileal abnormalities.
A deficiency of vitamin C (choice E), which is often called scurvy, is
characterized by easy bruising, perifollicular hemorrhages, purpura, poor
wound healing, bone lesions, and emotional changes. It is not commonly
associated with night blindness. It occurs in individuals with diets devoid of
citrus fruits and vegetables.
An 11-year-old girl with insulin-dependent diabetes mellitus is brought to the emergency
department by a friend's father because of severe abdominal pain and vomiting for the
past 12 hours. The friend's father says that she has been complaining of mild stomach
"cramps" and "thirst" for the past few days, but nothing this extreme. When he leaves the
room, she reluctantly admits that she has not been taking her insulin because she is
24
mad at her parents for going away to Europe and "leaving her" for 5 days. Her blood
pressure is 100/70 mm Hg, pulse is 98/min, and respirations are 30/min. Physical
examination shows dry skin and mucus membranes and diffuse abdominal pain.
Laboratory studies show:
Serum
Glucose
550 mg/dL
Sodium
138 mEq/L
Potassium 5.8 mEq/L
Chloride
94 mEq/L
Bicarbonate 10 mEq/L
Intravenous isotonic saline and insulin are given and she is admitted to the pediatric
intensive care unit for careful monitoring and management. Two hours later, potassium
is added, as her glucose and potassium levels begin to drop rapidly. All seems to be
going well until half an hour later when the nurse runs over to you frantically saying that
the patient suddenly complained of a headache, began to vomit, and became
"completely disoriented." You rush to the bedside to find her obtunded. The most
appropriate immediate management is to
A. add more potassium to the intravenous solution
B. add phosphate to the intravenous solution
C. add sodium bicarbonate to the intravenous solution
D. administer a bolus infusion of mannitol
E. increase the dose of insulin
Explanation:
The correct answer is D. This patient has diabetic ketoacidosis (DKA) and has most
likely developed cerebral edema, which should be treated with mannitol and
dexamethasone. If this is not effective, hyperventilation should be induced. DKA is
characterized by hyperglycemia, osmotic diuresis, metabolic acidosis, and elevated
ketones. The typical clinical presentation is abdominal pain, nausea, vomiting, polyuria,
and lethargy. It is usually precipitated by an infection, stress, a cessation of insulin
intake, or surgery. The initial treatment includes insulin and isotonic saline or Ringer's
lactate. As glucose and potassium levels begin to fall, potassium and glucose solutions
must be given. Bicarbonate is given to patients with severe acidosis. If the glucose level
is corrected too rapidly and glucose is not added to the intravenous fluids as the levels
fall below 300 mg/dL, cerebral edema may develop. Clinically, cerebral edema
manifests as acute altered mental status, vomiting, and a headache. A CT scan is used
to make the diagnosis.
Adding more potassium to the intravenous solution (choice A) would not be the
appropriate management of cerebral edema, which requires mannitol. This patient's
acute complication is inconsistent with hypokalemia, which is typically associated with
cardiac arrhythmias.
Adding phosphate to the intravenous solution (choice B) is an important part of the
25
treatment of DKA. However, this patient is most likely suffering from cerebral edema,
which is a life-threatening condition that requires rapid treatment with mannitol, not
phosphate. Patients with hypophosphatemia typically complain of muscle weakness.
Sodium bicarbonate (choice C) is typically used in severely acidotic patients with
hypotension. It is not used to treat cerebral edema.
Increasing the dose of insulin (choice E) is incorrect because this patient has cerebral
edema, which is most likely caused by the rapid fall of glucose, and so you would not
want the glucose levels lowered even more rapidly.
A 23-year-old man is admitted to the medical services for dehydration. He had just
completed a marathon that afternoon and was brought to the hospital by his sister who
found him to be lethargic and confused. His sister informs you that he has been training
very vigorously for the marathon and completed the marathon in near-record time by not
stopping for rehydration at all of the available rest stops. On examination, the patient is a
well-developed man. He is speaking using unclear words and is warm to the touch with
stable vital signs. His skin is very dry and his lips are chafed. His serum sodium is 163
mEq/L. The result is confirmed with the laboratory. The most appropriate management
at this time is
A. intravenous half normal saline repletion
B. intravenous lactated ringers repletion
C. intravenous normal saline repletion
D. oral free water repletion
E. oral thiazide diuretics
Explanation:
The correct answer is D. This patient has hypernatremia as a consequence of
insensible free water losses. He needs free water repletion with one half the free water
deficit being given in the first 12 hours and the remaining half over the next 24 hours.
The serum sodium should fall by no more than 0.5mEq/L/hour (12 mEq/day).
Intravenous half-normal saline repletion (choice A) will worsen the condition. Although
there is more free water in this preparation, the added sodium will likely worsen this
patient's condition.
There is no role for intravenous lactated ringers repletion (choice B) in correcting
hypernatremia since it has a similar sodium content as normal saline.
Intravenous normal saline repletion (choice C) will aggravate the condition by providing
only some free water and the remainder sodium. This is used to replete some forms of
hyponatremia.
Oral thiazide diuretics (choice E) are often a treatment for hypernatremia when salt
sodium excess is the primary problem. This can occur with hypertonic dialysis solutions.
26
A 32-year-old woman comes to the office because of palpitations and anxiety
for a few months. She further complains that, "My right eye is bulging out of
my head and I see double." Examination reveals visual acuity of 20/20 in both
eyes, exophthalmos of the right eye, and redness in both eyes, worse in the
left eye. You order a sensitive thyroid stimulating hormone test, which comes
back at 0.1 U/mL. At this time the most correct statement about this patient's
condition is:
A. Cigarette smoking has been shown to increase the severity of
exophthalmos in this disease
B. Diplopia observed in this condition is from transient cranial nerve
palsies
C. Exophthalmos and lid retraction improves as the patient's thyroid
hormone levels are appropriately treated
D. Ocular dryness, irritation, and redness are commonly observed in
this condition, but visual field deficits and blindness have not been
reported
E. Unilateral exophthalmos is a rare finding in this disease
Explanation:
The correct answer is A. This patient has Graves disease or thyroid
ophthalmopathy. Cigarette smoking has been linked to an increased severity
of thyroid ophthalmopathy. The exact reason for this is not known, but
patients who smoke should be informed of this association as further
encouragement to quit smoking.
The diplopia in Graves disease is from infiltration of the extraocular muscles
causing restriction of extraocular motility and not from cranial nerve palsies
(choice B).
The degrees of exophthalmos and thyroid function run different clinical
courses. Treatment of thyroid dysfunction is certainly indicated, but this will
not affect the patient's ocular findings (choice C). Furthermore, the ocular
findings of Graves disease may precede the onset of dysthyroidism or
become apparent many months after the thyroid function has been treated.
Ocular dryness, redness, irritation, and diplopia are all very common signs
and symptoms of Graves disease; however, the clinician should be aware
that compression of the optic nerve can occur. If unrecognized and not
treated, then an optic neuropathy can cause visual loss (choice D). All
patients with thyroid ophthalmopathy should be referred to an
ophthalmologist for evaluation.
Unilateral exophthalmos is not uncommon (choice E) and should not
eliminate the diagnosis of Graves disease. In fact, the most common cause
of unilateral exophthalmos is Graves disease.
A 46-year-old farmer is admitted to the hospital with confusion, profound weakness, and
27
hypotension. His primary care physician was contacted after obtaining a history from his
wife. One week prior to the presentation, the patient saw his primary care physician with
complaints of increasing fatigue and weakness for the past few months. Thyroid function
tests performed at that time were reported as normal according to the primary care
physician. Two days prior to admission, the farmer's wife noticed that he was even
weaker and complained of dizziness on standing. He was tremulous and sweaty. His
symptoms improved by eating food. He attributed that to hunger and did not report it to
his primary care physician. One day prior to his admission to the hospital, he developed
flu-like symptoms with a low-grade fever. On the day of admission, he experienced
increasing confusion, profound weakness, and inability to stand, because of
lightheadedness. On examination, the patient is drowsy, confused, and appears unwell.
His temperature is 37.2 C (99 F), blood pressure is 100/60 mm Hg supine, falling to
74/50 mm Hg when sitting up, and his pulse is 108/min. He is pale with cool extremities
and no skin pigmentation. No other abnormalities are noted on physical examination. A
capillary blood glucose measurement is 64 mg/dL. Initial laboratory studies show:
Appropriate initial management of this patient includes administration of
A. dextrose
B. dextrose and norepinephrine
C. dextrose, saline, and levothyroxine
D. saline, norepinephrine, and antibiotics
E. saline, steroids and antibiotics
Explanation:
The correct answer is E. This patient is dehydrated with postural hypotension and
circulatory failure. These findings are seen with adrenal insufficiency. Biochemically, the
patient has a low sodium concentration, high normal potassium concentration, and an
increased creatinine concentration. All findings are consistent with loss of
mineralocorticoid action. These are the features of primary adrenal failure. This patient
requires immediate management of adrenal crisis with adequate hydration with saline
and administration with intravenous steroid. Relatively minor urinary or respiratory tract
infections can precipitate adrenal crisis and should be appropriately treated.
The patient's hypoglycemia does not require specific management and will correct itself
without dextrose (choice A).
Dextrose is not indicated as stated above and norepinephrine (choice B) is not
indicated before adequate aggressive hydration for the correction of an adrenal crisis.
Dextrose, saline, and levothyroxine (choice C) are incorrect, because dextrose and
levothyroxine are not indicated. The patient's hypoglycemia should correct itself, and
28
there is no indication for dextrose or levothyroxine in this patient.
Although saline and antibiotics are indicated in this patient, norepinephrine (choice D) is
not indicated in the initial management of this patient.
A 3-month-old infant is brought to the office by her foster mother because of
feeding problems, constipation, and a "strange" discoloration of her skin. She
thinks that she was born at home and had not received any medical care.
She feeds her commercial infant formula. She has tried to increase her fluid
and give her prune juice, but she is still only having one hard bowel
movement every 3 days. Physical examination shows mildly jaundiced skin
with a "mottled" appearance, generalized hypotonia, coarse facial features, a
protruding tongue, and a hoarse cry. Rectal examination shows hard, brown,
guaiac-negative stool, and normal anal sphincter tone. The most appropriate
next step is to
A. measure galactose-1-phosphate-uridyl transferase levels
B. measure phenylalanine hydroxylase levels
C. order thyroid function tests
D. reassure her that this is normal and no studies are indicated
E. refer the patient to a surgeon for a rectal biopsy
F. send the patient to a geneticist for analysis of sex chromosomes
Explanation:
The correct answer is C. This patient most likely has congenital
hypothyroidism. Newborns born in hospitals in the United States are usually
screened for hypothyroidism. The clinical manifestations can be avoided
with early diagnosis and treatment. The features include prolonged jaundice,
poor feeding, hoarse cry, constipation, short stature, protruding tongue, dry
skin, myxedema, umbilical hernia, and developmental abnormalities. The
diagnosis is established by finding decreased levels of thyroxine and
triiodothyronine and an increased level of thyroid-stimulating hormone. The
treatment is thyroid hormone replacement. The most common causes of
congenital hypothyroidism are structural lesions of the thyroid or pituitary,
hormone synthesis defects, and maternal intake of radioiodine during
pregnancy.
The measurement of galactose-1-phosphate-uridyl transferase levels
(choice A) is used to diagnose galactosemia, which presents with jaundice,
hepatosplenomegaly, seizures, hypoglycemia, cataracts, and vomiting
following the consumption of galactose-containing foods (milk). Dietary
restriction of galactose-containing foods prevents these symptoms.
The measurement of phenylalanine hydroxylase levels (choice B) is used to
diagnose phenylketonuria, an autosomal recessive disorder which is
characterized by light hair and skin, a "mousy" odor, seizures, vomiting,
29
dermatitis, and growth retardation. The early diagnosis and the dietary
restriction of phenylalanine can prevent these symptoms.
Reassurance (choice D) is inappropriate because even though constipation
is very common in formula-fed infants, this girl's physical examination
reveals many abnormalities that are consistent with hypothyroidism, which is
also associated with constipation.
A rectal biopsy (choice E) is used to establish the diagnosis of Hirschsprung
disease, which is due to a lack of ganglion cells in the distal colon. It is very
unlikely that this infant has this relatively rar,e (1 in 5,000) disease that is
often suspected if a newborn does not have stool in the first 24 hours of life.
Infants with this disease often have a distended abdomen, and a rectum that
is devoid of stool. It is more likely that this infant with no previous medical
care, constipation, and other physical abnormalities, has hypothyroidism.
Analysis of sex chromosomes (choice F) would diagnose Turner syndrome,
which is usually characterized by a 45, X karyotype. Affected infant girls
usually have edematous hands and feet and congenital heart defects.
Childhood manifestations include short stature and primary amenorrhea.
A 33-year-old man comes to the office complaining of 3 months of severe headaches
preceded by sweating and palpitations. He denies any chest pain or shortness of breath
with these episodes. He has not taken any new medications and denies excessive
caffeine intake and illicit drug use. His temperature is 37.0 C (98.6 F), blood pressure is
120/70 mm Hg, pulse is 78/min, and respirations are 14/min. Physical and neurological
examinations are unremarkable. Thyroid function tests, a complete blood count, and a
24-hour urine cortisol are all within normal limits. Urine catecholamines are elevated.
You order a CT scan of the abdomen, which shows an adrenal mass. The most
appropriate next step is to
A. begin therapy with phenoxybenzamine
B. begin therapy with propanolol
C. consult a surgeon for emergent laparoscopic adrenalectomy
D. order serial CT scans to evaluate progression
E. perform a fine needle aspiration of the mass
Explanation:
The correct answer is A. This patient most likely has a pheochromocytoma. The classic
triad of headache, palpitations, and diaphoresis should suggest this diagnosis. Patients
are frequently hypertensive but sometimes the hypertension is paroxysmal and a
normal blood pressure is found on exam. Prior to surgery this patient must be started
on an alpha-blocker (phenoxybenzamine) to avoid intraoperative hypertensive crisis.
Laparoscopic adrenalectomy is the treatment of choice for a pheochromocytoma.
Treatment with a beta blocker (choice B) is initiated only after a patient is started on an
alpha blocker. Unopposed alpha stimulation can worsen hypertension in patients with a
30
pheochromocytoma.
Laparoscopic adrenalectomy (choice C) is the treatment of choice for
pheochromocytoma but medical stabilization is essential prior to surgery.
Pheochromocytoma is not an indication for emergent surgery.
Serial CT scans (choice D) are important in the management of non-functioning adrenal
masses (incidentaloma). When an adrenal mass is discovered incidentally and it is <
6cm repeat imaging is indicated to ensure that the mass is not quickly growing. A
rapidly growing adrenal mass is suggestive of malignancy.
Fine needle aspiration (choice E) is an important tool in the workup of an adrenal mass.
However, prior to aspirating any adrenal mass, pheochromocytoma must be ruled out to
avoid precipitation of hypertensive crisis. Fine needle aspiration is not indicated in the
management of pheochromocytoma since it can exacerbate a hypertensive crisis.
A 17-year-old high school student is admitted to the hospital for treatment of
anxiety disorder when he reports acute loss of vision in the left eye. His past
medical history is significant for intractable anxiety disorder for the past 3
years. Physical examination reveals bilateral proptosis. There is no vision in
the left eye and vision in the right eye is normal. Extraocular movements are
intact bilaterally. The sinuses and ears are normal on exam. An MRI of the
brain is urgently performed and is normal. Recent laboratory studies show:
The next step is
A. buspirone administration
B. coumadin administration
C. diazepam administration
D. EEG
E. funduscopic examination
F. heparin administration
Explanation:
31
The correct answer is E. This patient's symptoms of anxiety, bilateral
proptosis, and a decreased thyroid stimulating hormone (TSH) are
consistent with hyperthyroidism with thyroid ophthalmopathy. A thorough
funduscopic exam will reveal papilledema. An uncommon complication of
thyroid ophthalmopathy (5% of cases) is optic neuropathy from edema of the
extraocular muscles with secondary compression of the optic nerve.
Anxiolytic therapy with buspirone (choice A) may be necessary, but
treatment of the underlying hyperthyroidism is the primary clinical concern.
The next most appropriate step is to perform a thorough funduscopic
examination to evaluate for papilledema.
Anticoagulation (choice B) is not necessary. This patient is suffering from
optic nerve compression secondary to extraocular muscle edema, not a
stroke.
Anxiolytic therapy with diazepam (choice C) may be necessary, but
treatment of the underlying hyperthyroidism is the primary clinical concern.
Vision loss is a rare complication of a seizure which could be evaluated by
EEG (choice D). Seizure as a cause of vision loss is an unlikely possibility
given that this patient has anxiety, bilateral proptosis, and an elevated
thyroid stimulating hormone (TSH). These findings are all consistent with
hyperthyroidism and secondary thyroid ophthalmopathy.
Anticoagulation with heparin (choice F) is not necessary. This patient is
suffering from optic nerve compression secondary to extraocular muscle
edema, not a stroke.
A 31-year-old man with insulin dependent diabetes mellitus is admitted to the
hospital because of a severe diabetic crisis. His wife reports that over the
past few days he has developed "the flu." During that time, his blood sugars
had become much more difficult to manage despite diligent attention. She
states that over the past 24 hours his sugars have been above 500 mg/dL
despite insulin and diet control, that have always controlled the sugars in the
past. The patient began to breathe very fast in the last 8 hours and he has
become somewhat confused in the past 4 hours. His temperature is 38.0 C
(99.6 F), blood pressure is 140/85 mm Hg, pulse is 88/min, and respirations
are 24/min. His urine is 4+ for ketones and sugar. A fingerstick blood glucose
reveals a blood sugar of 850 mg/dL. An arterial blood gas would most likely
show:
A. PaCO2 14 mm Hg, pH 7.12, PaO2 60 mm Hg
B. PaCO2 14 mm Hg, pH 7.22, PaO2 90 mm Hg
C. PaCO2 14 mm Hg, pH 7.38, PaO22 90 mm Hg
D. PaCO22 35 mm Hg, pH 7.36, PaO2 90 mm Hg
32
E. PaCO2 68 mm Hg, pH 6.80, PaO2 60 mm Hg
Explanation:
The correct answer is B. When looking at arterial blood gases, examine the
pH to identify the acid-base disturbance and then determine whether the
acid-base disturbance is respiratory (change in CO2) or metabolic. The
relationship between PaCO2 and pH determines whether the condition is
acute or chronic. Chronic conditions have a pH closer to 7.4 than would be
predicted based upon PCO2 because of compensation. This patient has
diabetic ketoacidosis. This condition occurs when some event "pushes" the
patient over the edge and they are unable to regulate glucose balance.
Typical events include infection or stress. For this man, his primary problem
is a metabolic acidosis that will cause him to hyperventilate to compensate
for. His oxygenation will be essentially normal since he has no pulmonary
pathology: PaCO2 14 mm Hg, pH 7.22, and PaO2 90 mm Hg.
A PaCO2 of 14 mm Hg, pH of 7.12, and PaO2 of 60 mm Hg (choice A)
reflects a profound metabolic acidosis with hypoxemia. This is not DKA but
perhaps a condition such as sepsis or cyanide poisoning.
A PaCO2 of 14 mm Hg, pH 7.38, and PaO2 90mm Hg (choice C) represents
a chronic acidosis. The pH is mildly acidic with a very low PaCO2. For this
PaCO2, the patient should be alkalotic, but since he is not, it must have
increased the pH from a very low level to near normal. This is the hallmark
of a compensated metabolic acidosis. This can be seen with conditions such
as Type I and II renal tubular acidosis.
A PaCO2 of 35 mmHg, pH 7.36, and PaO2 of 90 mm Hg (choice D) is a
compensated metabolic acidosis. The PaCO2 is nearly normal which
suggests the acidosis is mild. Such mild acidosis can occur with specific
renal tubular disorders or with chronic diarrhea.
A PaCO2 of 68 mmHg, pH 6.80, and PaO2 of 60 mm Hg (choice E)
represents a combined metabolic/respiratory acidosis. The patient has a
severe acidosis (pH), the expected PaCO2 should be low to compensate.
Instead, it is high. The patient also has hypoxemia. This is typical of severe
respiratory failure. Hypoxia causes a metabolic acidosis and the pulmonary
system cannot compensate.
A 44-year-old woman comes to see you for routine check up. While in your
office, she starts crying hysterically, stating she has not been able to sleep for
the last few months. Also, her mind has been "racing," her palms and soles
are sweaty at all times, and she has thinning of her hair. She denies any
alcohol or tobacco use, but admits to 2 cups of coffee a day. Her mother has
bipolar disorder and her aunt has obsessive-compulsive personality disorder.
Her blood pressure is 130/80 mm Hg and pulse is 100/min. There is notable
exophthalmos bilaterally. He skin appears moist and warm. On the pretibial
regions, there is a woody induration with pitting edema. The most appropriate
next step in evaluation is to
33
A. determine testosterone level
B. give her aluminum chloride for her sweaty palms and reassure her
this is all psychological
C. order thyroid function tests
D. refer her to an ophthalmologist for evaluation of the exophthalmos
E. refer her to a psychiatrist for evaluation of a psychiatric disorder
Explanation:
The correct answer is C. Ordering a thyroid function test is correct, because
this patient demonstrates not only physiological hyperthyroid changes (i.e.
increased heart rate), but also cutaneous findings classic for Graves
disease. Skin changes are distinctive in hyperthyroidism. The cutaneous
surface is warm, moist, and smooth textured. Palmar erythema or facial
flushing may be seen. The hair is thin and has a downy texture and
nonscarring alopecia may be observed. Graves disease has a female to
male ratio of 7:1. Thyroid acropachy is characterized by digital clubbing and
diaphyseal proliferation of the periosteum in acral and distal long bones
(tibia, fibula, ulna, and radius). Pretibial myxedema consists of bilateral
localized, cutaneous accumulations of glycosaminoglycans and occurs in
4% of patients who have or have had Graves disease. Improvement in
plaques of pretibial myxedema have resulted from intralesional injections of
triamcinolone acetonide and with clobetasol solution under Duoderm
occlusion, applied once weekly for 4-6 weeks. Systemic steroids are of no
benefit.
Checking testosterone level (choice A) is incorrect, because an elevated
testosterone level would only account for hair thinning, but not her other
physiologic and cutaneous changes.
Giving her aluminum chloride (choice B) is incorrect, because this solution
will only alleviate sweaty palms and soles for this patient, but does not help
to diagnose and treat the underlying issue.
Referring her to ophthalmology (choice D) is incorrect, because eventually
this patient may need to see an ophthalmologist for severe exophthalmos,
but diagnosing Graves disease is the more appropriate first step for this
patient.
Despite her family history of psychiatric illnesses, referral to psychiatry
(choice E) is incorrect, because this patient's manic appearance is most
likely secondary to thyroid hormone imbalance.
A 54-year-old woman comes to the office for a follow-up examination 6 weeks after
starting lovastatin for elevated cholesterol. She has been a patient of yours for years,
and you have treated her for hypertension, an episode of gout, and anemia caused by
uterine leiomyomas that were treated with a hysterectomy 5 years ago. She has no
complaints at this time and is in a rush to pick up her children from a soccer game. Her
34
blood pressure is 130/80 mm Hg and her pulse is 65/min. Physical examination is
unremarkable. The most appropriate course of action is to order cholesterol levels and to
A. let her go pick up her children
B. obtain uric acid levels
C. order creatine kinase levels
D. order liver function tests
E. remind her to call you if she develops any side effects from the medication
Explanation:
The correct answer is D. Abnormal liver function is one of the main side effects
associated with HMG-CoA reductase inhibitors, which are one of the most common
classes of drugs prescribed for elevated cholesterol. While this side effect is relatively
uncommon (1-2%), it can be very serious. It is important to monitor cholesterol and liver
function tests at 6 weeks and 12 weeks after the initiation of therapy or when the
dosage is increased, and then every 4-6 months.
It is important to order liver function tests and to remind her to call you if she develops
any side effects from the medication, before you let her go pick up her children (choice
A).
There is no apparent reason to measure uric acid levels (choice B) in this patient at this
time. Niacin, not HMG CoA reductase inhibitors, is associated with elevated uric acid
levels. Even though this patient has a history of gout, she does not have symptoms now
and she is specifically at the office for a follow-up examination after starting lovastatin.
Myositis is one of the other side effects of HMG CoA reductase inhibitors, but this too is
relatively uncommon. Myositis occurs more frequently when combined with other
cholesterol lowering agents. Discontinuation of the medication is important if these
symptoms occur because rhabdomyolysis with renal failure and death can occur. The
routine measurement of creatine kinase levels (choice C) is not recommended. It is
usually done when patients complain of muscle aches and cramps.
While it is important to remind her to call you if she develops any side effects from the
medication (choice E), such as muscle aches, you first need to order liver function tests.
A 83-year-old man with a history of obesity, diabetes mellitus type 2,
hypertension, chronic renal insufficiency, hyperlipidemia, and coronary artery
disease comes to your office after being awakened from sleep by severe pain
in his "right first toe." He says that he had a sudden onset of acute pain in the
toe rapidly followed by erythema, swelling, tenderness, and warmth. His
temperature is 37.0 C (98.6F), blood pressure is 170/60 mmHg, pulse is
97/min, and respirations are 19/min. Physical examination is normal except
for swelling and severe tenderness over the metatarsophalangeal joint on the
right foot. At this time the most accurate statement about this patient's
condition is:
35
A. Allopurinol would be a reasonable therapy now by decreasing his
serum uric acid levels
B. Decreasing his dietary protein may have some role in decreasing
frequency of recurrent attacks
C. Elevated serum urate levels in the past should have been treated to
decrease the likelihood of attacks
D. Most patients will only experience a single attack in their lifetime
E. Overproduction of uric acid is the etiology of these attacks in most
patients.
Explanation:
The correct answer is B. This patient has gout. Pain in the MTP joint of his
first toe is a classic symptom and is known as podagra. All of the comorbid
medical conditions associated with gout are listed in the case and include
diabetes, hypertension, coronary artery disease, hyperlipidemia, obesity,
and chronic renal disease. Excessive dietary purine intake along with
alcohol may also contribute. Patients with gout should be encouraged to
modify their diets to minimize secondary causes of hyperuricemia.
Allopurinol (choice A) is a xanthine oxidase inhibitor which is an effective
therapy for hyperuricemia. Allopurinol has no role in the treatment of acute
gout since it may cause the mobilization of tophi, thereby causing increased
pain. It is useful to keep the uric acid level within normal limits. NSAIDS are
the treatment of choice for acute gout. Colchicine and steroids are other
alternatives.
Asymptomatic hyperuricemia (choice C) without evidence of gout is not
typically treated. Most physicians would wait until the first attack of gout
before initiating allopurinol treatment. Of note, uric acid levels are not helpful
in the diagnosis of acute gout because they can be normal in some patients.
Most patients have recurrences of gout in their lifetime. The majority of
patients even have recurrences within the first year. Therefore a single
attack, (choice D), is incorrect.
Overproduction of uric acid (choice E) is responsible for about 10% of the
patients with gout. This can be a primary process secondary to defects in
the purine enzyme pathways or can be secondary from alcohol, heme
malignancy, or chemotherapy. 90% of the patients with gout are underexcreters, which means they excrete less than 700 mg of uric acid per day.
A 54-year-old woman comes to the office complaining of "sluggishness",
decreased concentration, depression, and weight gain of 11 pounds over the
last 7 months despite dieting and exercising 3 days a week. Her temperature
is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and
respirations are 12/min. Physical examination reveals a diffuse goiter, dry
skin, and a slightly hoarse voice. The remainder of her physical exam is
normal with the exception of "hung up" ankle jerk reflexes bilaterally.
36
Laboratory studies show:
The most appropriate next step in management is to
A. begin therapy with fluoxetine
B. begin therapy with levothyroxine
C. begin therapy with lovastatin
D. begin therapy with propylthiouracil (PTU)
E. begin therapy with vitamin B12 and folate
Explanation:
The correct answer is B. This patient has subclinical hypothyroidism
(elevated TSH with a normal free T4). Treatment is recommended if the
patient has symptoms. Ordering further studies such as thyroid function test
or thyroperoxidase antibody will help support your diagnosis. Clues to the
diagnosis of hypothyroidism include weight gain, difficulty concentrating,
hoarse voice, dry skin, thinning of the eye brows laterally, goiter, etc.
Treatment with levothyroxine should be initiated in our patient since she has
many of the classic symptoms of hypothyroidism. It is likely that this patient,
if untreated, would develop clinical hypothyroidism in the future, which would
require treatment. In a young, otherwise healthy person, therapeutic doses
of levothyroxine can be started initially. In older patients or patients with
heart disease low-dose levothyroxine should be started with a slow titration
to therapeutic doses to avoid cardiac complications.
Depression is often a part of hypothyroidism and the two disorders can often
mimic each other. Prior to starting a patient on an SSRI (choice A),
reversible causes of depression (such as hypothyroidism) need to be
excluded. Since depression is so prevalent, it is reasonable to reevaluate
this patient for depression after she is euthyroid.
Therapy with a statin drug (choice C) is not appropriate at this time. This
patient does have an elevated LDL and total cholesterol but two things need
to be remembered: first, hypothyroidism can cause high cholesterol so it is
necessary to recheck the patient's cholesterol when euthyroid. Second, this
patient needs a trial of exercise and diet prior to being placed on a lipidlowering drug.
Propylthiouracil (choice D) is a therapy for hyperthyroidism, not
37
hypothyroidism. It acts by inhibiting the iodination of thyroid hormone and
acts to block the peripheral conversion of T3 to T4.
This patient has a macrocytic anemia, which is often associated with B12
and folate deficiency (choice E). A less common cause of macrocytic
anemia is hypothyroidism. This patient's anemia may resolve once treatment
with levothyroxine is initiated.
A 35-year-old woman comes to the office because of tremors, weakness,
weight loss despite an increased appetite, frequent bowel movements, and
"itchy legs." She does not drink alcohol or caffeine and she does not smoke
cigarettes. She appears anxious and fidgety, and has a "frightened" look. Her
blood pressure is 120/80 mm Hg and pulse is 88/min. Physical examination
shows a proptosis with stare and lid lag. The thyroid gland is lobular and
asymmetrically enlarged. There are waxy, infiltrated plaques over the dorsum
of her legs and the affected area has a peau d'orange appearance. An ECG
shows sinus tachycardia. Laboratory studies show:
Treatment options are discussed, and she decides upon radioactive iodine. In
discussing radioactive iodine therapy with the patient, you should inform her
that
A. continuous or repeated doses of radioiodine are usually necessary
B. hepatitis, arthralgias, agranulocytosis, and a rash are common side
effects of radioiodine therapy
C. patients treated with radioiodine will often require replacement
doses of thyroid hormone within 10 years
D. radioiodine therapy is the treatment of choice if she is currently
pregnant
E. there is plenty of evidence that the dose of radioiodine that she will
receive has leukemogenic effects
Explanation:
The correct answer is C. This patient has Grave's disease, which is a
common cause of hyperthyroidism, and it important to discuss the
advantages and disadvantages of the treatment options. The major
disadvantage of radioiodine therapy is that 40-70% of patients will develop
hypothyroidism and require thyroid hormone replacement within 10 years.
Grave's disease is characterized by diffuse goiter, dermopathy, and
ophthalmopathy. The clinical manifestations are that of hyperthyroidism and
include palpitations, tremors, weakness, weight loss despite an increased
appetite, frequent bowel movements, heat intolerance, and oligomenorrhea
or amenorrhea. Proptosis, lid lag, and stare are often present. The
38
dermopathy, which is called pretibial myxedema, is usually characterized by
waxy, infiltrated plaques over the dorsum of the legs and a peau d'orange
appearance. Laboratory studies show low or undetectable levels of TSH,
and elevated levels of T4, T3, and the RAIU and RT3U. Radioactive iodine
therapy is a good choice for treating hyperthyroidism in adult patients,
patients with previous thyroid surgery, and those who cannot undergo
surgery. Long-term antithyroid therapy with methimazole or propylthiouracil
is usually used in children.
It would be incorrect to inform her that continuous or repeated doses of
radioiodine is usually necessary (choice A). Continuous or repeated therapy
with antithyroid drugs (methimazole or propylthiouracil) is often necessary.
It would be incorrect to inform her that hepatitis, arthralgias, agranulocytosis,
and a rash are common side effects of radioiodine therapy (choice B)
because these are associated with antithyroid drugs, not radioiodine
therapy.
It would be incorrect to inform her that radioiodine therapy is the treatment of
choice if she is currently pregnant (choice D) because radioiodine therapy
should never be given to pregnant women. Antithyroid drugs are usually
used during pregnancy.
It would be incorrect to inform her that there is plenty of evidence that the
dose of radioiodine that she will receive has leukemogenic effects (choice E)
because this is not true. There is no evidence to support this statement (in
adults).
A 32-year-old woman has had severe right-sided flank pain for the past 2 days. You
have been taking care of her for the past year for rheumatoid arthritis. She has been
steroid dependant and recently started taking methotrexate as a steroid-sparing agent.
Her usual rheumatoid arthritis flares occur in her hands and wrists, as well as a macular
rash. Her blood pressure is 100/50 mm Hg lying down and 80/40 sitting up. Her pulse is
120/min lying down and was 145/min sitting up. She looks very ill and fatigued. Physical
examination shows moderate right upper quadrant abdominal tenderness and severe
right sided flank tenderness. She is hydrated with lactated ringer's solution in the office
while her laboratory results are pending. After 2 liters of intravenous fluids, the patient's
blood pressure is 90/45 mm Hg lying down and she still feels too weak to stand up.
Laboratory studies show:
39
Urinalysis: >25 WBC, 5-10 WBC, + leukocyte esterase, + nitrate, + ketones, no glucose
The most appropriate initial step in management is to
A. administer hydrocortisone, intravenously
B. call for an endocrinology consult
C. check serum cortisol level
D. infuse type O- blood
E. start antibiotics, intravenously
Explanation:
The correct answer is A. This patient is on chronic steroids for her rheumatoid arthritis.
She has a urinalysis consistent with a urinary tract infection and given her flank
tenderness and elevated WBC, probably has pyelonephritis. However, given her
chronic steroid use, this patient is relatively adrenal insufficient and can't mount a stress
response. She therefore has orthostatic hypotension with eosinophilia and a low
glucose. Additionally, her serum sodium is low and her potassium is high, another
useful clue to her mineralocorticoid deficiency. If adrenal insufficiency is suspected,
then stress dose IV steroids would be the initial management
An endocrinology consult (choice B) would be too time consuming and would just delay
life saving treatment.
Checking serum cortisol levels (choice C) would be helpful to solidify the diagnosis of
adrenal insufficiency. However, IV steroids need not be delayed given this patient's
history and classic lab findings. Furthermore, this question asks for the next step in
management, not diagnosis.
This patient doesn't require a blood transfusion (choice D) for her anemia. It is most
likely her steroid deficiency that is contributing to her hypotension, not her chronic
40
anemia.
This patient will require IV antibiotics (choice E) for the pyelonephritis, but the first initial
step for management would include stress-dose steroids.
A 33-year-old woman comes to the office because of generalized weakness and a "pins
and needles" feeling in her lower extremities for the past 3 weeks. She states that she
feels "unsteady" on her feet. She exercises daily, rarely drinks alcohol, and is a strict
vegetarian. Since this is the first time you have met this woman, she tells you that she
has not had any major illnesses, but has been hospitalized multiple times over the past
few years for anorexia nervosa. Her temperature is 37 C (98.6 F), blood pressure is
110/70 mm Hg, pulse is 60/min, and respirations are 18/min. Examination shows
weakness of the proximal and distal muscles of the lower extremities. There is impaired
proprioception and vibratory sensation. Deep tendon reflexes are increased. The gait is
ataxic. The most likely diagnosis is
A. Guillain-Barre syndrome
B. Lambert-Eaton syndrome
C. myasthenia gravis
D. polymyositis
E. subacute combined degeneration of the spinal cord
Explanation:
The correct answer is E. This patient most likely has subacute combined degeneration
of the spinal cord, which is a condition caused by vitamin B12 deficiency. It is most
often caused by pernicious anemia, but it may be acquired in patients with strict
vegetarian diets or small bowel disease. The clinical manifestations include weakness,
paraesthesias, loss of vibratory sensation, increased deep tendon reflexes, and
extensor plantar responses. The gait is ataxic. Mental changes may also occur. The
diagnosis is usually established by measuring serum vitamin B12 levels. The treatment
is vitamin B12 replacement.
Guillain-Barre syndrome (choice A) is an acquired demyelinating neuropathy that
usually follows a viral respiratory infection or immunizations. It is characterized by
ascending weakness. Sensation is intact. A main diagnostic clue is absent deep tendon
reflexes.
Lambert-Eaton syndrome (choice B) is a neuromuscular disorder that causes proximal
muscle weakness, ptosis, and diplopia. Deep tendon reflexes are depressed or absent.
Repetitive nerve stimulation shows increased responses. Small-cell carcinoma of the
lung has been associated with this disorder.
Myasthenia gravis (choice C) is a neuromuscular disorder due to autoantibodies to the
acetylcholine receptors. It is characterized by weakness and easy muscle fatigability.
The extraocular and eyelid muscles are affected, leading to diplopia and ptosis. Deep
tendon reflexes are preserved.
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Polymyositis (choice D) is a skeletal muscle disorder that is characterized by
progressive proximal muscle weakness. Patients often complain of difficulty climbing
stairs and brushing hair. Ocular muscles are generally not affected. Creatine kinase is
elevated. Muscle biopsy and electromyography confirm the diagnosis.
A 41-year-old woman comes to the office because of a 40-pound weight gain in the past
6 months. She is very upset because she has always been thin and never had to watch
her diet before. She has no change in appetite, no change in eating habits, and has no
other symptoms. She takes no medications, does not drink alcohol, and smokes a pack
of cigarettes a day for the past 10 years. She rollerblades with her daughter every
evening and tries to eat a well-balanced, low-fat diet. She denies anxiety and any
psychiatric problems. She tells you that her mother and sister have always been
overweight and they always complain about their "apple-shaped" bodies. Her
temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and
respirations are 16/min. Physical examination shows an obese abdomen and thin lower
extremities, but is otherwise unremarkable. The most appropriate next step is to
A. determine thyroid stimulating hormone levels
B. order a biochemical profile
C. order a dexamethasone suppression test
D. refer her to a nutritionist
E. schedule a CT scan of the abdomen
Explanation:
The correct answer is B. The initial work-up for weight gain is a detailed history,
including medication and drug use and recent smoking cessation, and a biochemical
profile. A biochemical profile may indicate the presence of diabetes mellitus or Cushing
syndrome. Diabetes will most likely lead to an elevated glucose, while Cushing is
sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis,
hyperglycemia, and hypercholesterolemia. An individual with an "apple-shaped" body
typically has a large abdomen and chest and thin legs. A "pear-shaped" body typically
refers to a thin torso with larger hips, buttocks, and legs. This is included in the vignette
to show that the patient's "obese abdomen" is consistent with her family's body type
and is not necessarily associated with Cushings or any other conditions.
Determining thyroid stimulating hormone levels (choice A) is appropriate in the
evaluation of weight gain if there is a negative drug history, no recent smoking
cessation, and a normal biochemical profile. Since hypothyroidism is part of the
differential diagnosis for weight gain, you should consider it early in the work-up, but a
biochemical profile should be performed first.
A dexamethasone suppression test (choice C) is part of the initial evaluation of Cushing
syndrome. You should first order a biochemical profile to determine if this diagnosis is
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more likely than diabetes mellitus.
Referring her to a nutritionist (choice D) is inappropriate at this time. The case says that
the patient has had weight gain with no change in appetite or eating habits. She
requires evaluation for a medical condition, such as Cushing syndrome, diabetes
mellitus, thyroid disease, (even though this is usually associated with a poor appetite),
and fluid overload.
A CT scan of the abdomen (choice E) may be used to visualize an adrenal mass
leading to Cushing syndrome and weight gain. It may be ordered after a biochemical
profile, dexamethasone suppression test, and plasma cortisol. This study is not
appropriate at this time.
A 51-year-old man comes to the clinic for a pre-employment examination. He
has diet-controlled diabetes mellitus for 25 years, hypertension, glaucoma,
mild peripheral vascular disease, and osteoarthritis. His medications include
lisinopril, atenolol, aspirin, and acetaminophen as needed for pain. His blood
pressure is 160/80 mm Hg and pulse is 61/min. His examination is notable for
a left carotid bruit, a 2/6 systolic ejection murmur heard best at the left sternal
border, and clear lungs. His abdomen is soft with no masses but there is a
previously appreciated abdominal bruit. He hands you a piece of paper that
shows that his last BUN and creatinine were 65 mg/dL and 1.6 mg/dL
respectively. His last HA1C value was 8.3%. The most accurate statement
concerning this patient's condition is:
A. He has normal renal function
B. He has poorly controlled diabetes and severe diabetic renal
disease
C. He has renal insufficiency
D. He is not a candidate for a renal transplant
E. He requires hemodialysis
Explanation:
The correct answer is C. A BUN and creatinine as high as this patient's
reflect a glomerular filtration rate that is below normal, therefore indicating
renal insufficiency.
By definition this is renal insufficiency and not normal renal function (choice
A).
Although this patient has a HA1C level of 8.3% reflecting a mean blood
glucose concentration of greater that 225 mg/dL and therefore poorly
controlled diabetes, he does not have severe diabetic renal disease (choice
B) based upon the fact that he has only mildly elevated renal indices.
The evaluation of patient as a transplant candidate is a complex process
involving medical, psychiatric, and social issues and since we have no
43
information on most of these points, it is not possible to say that this patient
is not a candidate for a renal transplant (choice D).
There are five indications for hemodialysis: uremia, hyperkalemia, acidosis,
volume, and uremic pericarditis. Since this patient has none of these he
does not require hemodialysis (choice E).
A 26-year-old man comes to the office for a periodic health maintenance examination.
He has no complaints at this time and does not take any medications. His temperature is
37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are
12/min. Physical examination reveals a single, firm nodule in the left lobe of the thyroid
gland. It is fixed and placed with swallowing. The remainder of his examination is
normal. Radioactive iodine thyroid scintiscanning reveals that the nodule is "cold".
Thyroid function tests show TSH 1.14 mU/mL, T3 134 nmol/L, thyroxine 8 nmol/L. The
most appropriate next step is to
A. advise the patient to return in 3 months to evaluate the nodule for change in
size
B. begin 6 months of suppressive therapy with thyroxine
C. begin therapy with propylthiouracil
D. order a thyroid ultrasound in 3 months to evaluate for additional nodules
E. perform a fine needle aspiration of the nodule
Explanation:
The correct answer is E. This patient presented with a thyroid nodule that is suspicious
for malignancy. Risk factors for thyroid cancer include radiation therapy to the neck in
childhood and family history of thyroid cancer. The fact that the nodule is firm and fixed
in place is suggestive of malignancy. Thyroid malignancies are more common in men
than in women and more nodules in young patients are malignant than in older patients.
Radioactive iodine thyroid scintiscanning is a test which tells us which areas of the
thyroid gland are more active and which are less active. Most thyroid malignancies are
less active (i.e., cold). The appropriate management of this patient is a fine needle
aspiration of the nodule. This can be done safely in experienced hands and has very
few complications. It is of great benefit to the physician because it provides tissue to
make a definitive diagnosis and guide treatment.
Serial neck exams (choice A) for change in size of the nodule is inappropriate because
thyroid cancer found in its early stages is often curable.
Thyroxine therapy (choice B) is important in the management of thyroid cancer and is
often used after the thyroid cancer is removed with surgery. Since TSH can stimulate
cancers to grow more rapidly it is beneficial to suppress TSH after someone is
diagnosed with a thyroid cancer. The dose of Levothyroxine used is the highest dose
possible to suppress TSH without causing the patient to be symptomatically
hyperthyroid.
Propylthiouracil (choice C) inhibits the oxidation of iodide thereby decreasing the
44
production of thyroid hormone and inhibiting peripheral conversion of T3 to T4 in the
blood. It is used in the management of Graves disease as well as other hyperthyroid
states. It is not useful in the management of a thyroid nodule.
Thyroid ultrasound (choice D) is sometimes valuable in the work-up of a thyroid nodule.
An ultrasound can detect small nodules that even very experienced hands cannot
palpate. However these small nodules rarely have malignant potential and a biopsy of
these nodules hasn't been shown to improve mortality. Also, there is no reason to wait
3 months for this evaluation. A FNA should be performed with or without an ultrasound
at this visit or as close to this time as possible, not in 3 months.
Explanation:
The correct answer is E. This patient has true hyponatremia and his exam suggests that
his volume status is hypovolemic. A low urine sodium suggests that he is retaining all of
his filtered sodium in an attempt to relieve his hyponatremia. The therapy is repletion of
volume and salt. One half of the total sodium deficit should be repleted in the first 12
hours, with the remainder given over the remaining 24 hours. The sodium should rise by
no more than 0.5 mEq/L/hour (12 mEq/day). The rate of correction is done in this
manner to decrease the possibility of central pontine demyelinosis.
Fluid restriction (choice A) is the treatment of choice for hypervolemic hyponatremia
(congestive failure or cirrhosis) and with the syndrome of inappropriate anti-diuretic
hormone (SIADH).
Intravenous bicarbonate (choice B) is not necessary to correct this patient's acid-base
deficit. Although his bicarbonate is low, this is likely a result of his diarrhea and until his
pH is known, there is no reason for concern.
There is, in genera, little indication for intravenous hypertonic saline (choice C) as it is
dangerous and can cause great harm when used to correct hyponatremia if extreme
care is not taken.
Intravenous hypotonic saline (choice D) will aggravate the hyponatremia by giving free
water.
A 77-year-old man with comes to the emergency department with left knee
swelling and intense pain for 7 hours. He has a history of hypertension,
treated with hydrochlorothiazide, alcohol abuse, and chronic renal
insufficiency with a baseline creatinine of 3.4 mg/dL. His temperature is 37.3
C (99.2 F). Physical examination shows an erythematous, warm, tender
knee. The remainder of the examination is unremarkable. You aspirate fluid
from his knee and send it for evaluation. The results come back as
"negatively birefringent crystals." The most appropriate management at this
time is to administer
A. allopurinol
B. aspirin
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C. colchicine
D. indomethacin
E. intraarticular steroids
Explanation:
The correct answer is E. Steroids, especially intraarticular steroids, are very
effective when NSAIDs (which are the treatment of choice for gout) are
contraindicated. In this patient, chronic renal insufficiency is a relative
contraindication to NSAID use. Therefore, intraarticular steroids would likely
give him relief from his pain by decreasing inflammation and provide
treatment with few systemic effects.
Allopurinol (choice A) is a xanthine oxidase inhibitor, which is an effective
therapy for hyperuricemia. Allopurinol has no role in the treatment of acute
gout since it may cause the mobilization of tophi, thereby causing increased
pain. It is useful to keep the uric acid level within normal limits and should be
started after the acute attack has resolved to prevent recurrences. Do not
forget to keep a patient's comorbidity in mind prior to prescribing treatments.
This patient would likely benefit from decreasing his alcohol intake and
changing his antihypertensive medication to one that will not increase uric
acid levels.
Aspirin (choice B), especially low-dose aspirin, may increase uric acid levels
by inhibiting renal excretion of uric acid. Aspirin is therefore not indicated in
the treatment of gout.
Colchicine (choice C) is an effective treatment for gout but there are several
side effects associated with its use. It is often associated with severe GI side
effects. At high doses (especially IV therapy), bone marrow suppression can
occur. Liver disease and kidney disease may increase colchicine levels and
should be avoided in these patients if possible.
NSAIDs, such as indomethacin, (choice D) are the treatment of choice for
most patients with gout. Typically, treatment begins with high dose NSAIDs,
which are rapidly tapered. This patient has kidney disease and therefore
should not be given high-dose NSAIDs.
A 61-year-old man with angina, hypertension, hypercholesterolemia, and peptic ulcer
disease comes to the clinic with a recurrent right great toe pain that has been severe for
the past 2 days. His medications include atenolol, lovastatin, famotidine, and an
occasional aspirin. Physical examination shows an obese man with an edematous,
erythematous hallux metatarsophalangeal joint. Examination is otherwise unremarkable.
X-ray of the right great toe demonstrates an edematous hallux metatarsophalangeal
joint. There is no fracture or bony erosions. The most appropriate pharmacotherapy at
this time is
A. acetaminophen
46
B. allopurinol
C. colchicine
D. indomethacin
E. prednisone
Explanation:
The correct choice is C. This patient is presenting with signs and symptoms of gout.
Gout is a crystal-induced arthropathy that often presents in older, obese men. Over
time, crystal deposits in the joints cause an erosive arthropathy. Colchicine may be
used as an alternative to nonsteroidal antiinflammatory medications (NSAID) when
there is a history of peptic ulcer disease, excessive bleeding, or intolerance to NSAIDs.
Colchicine may also be used as a prophylactic treatment for gout.
Acetaminophen (choice A) is not indicated for an acute gout attack because of its lack
of antiinflammatory activity.
Allopurinol (choice B) is used to prevent gouty attacks. It serves no role in an acute
attack.
Indomethacin (choice D) is a type of nonsteroidal antiinflammatory medication (NSAID)
that is relatively contraindicated given the patient's history of peptic ulcer disease.
However, indomethacin is often considered one of the typical first-line agents for acute
gout attacks.
Oral steroids (choice E) are not typically used for an acute gouty attack. Intravenous
glucocorticoids are sometimes considered for patients who cannot tolerate oral
medications or others who have not responded to other therapies. Intraarticular methyl
prednisone or betamethasone is generally reserved for patients with acute gouty
monoarticular disease. Steroids are used extensively to treat other inflammatory
arthritides like rheumatoid arthritis.
A 63-year-old man comes to the clinic complaining of acute left toe pain that began last
night while he was lying in bed. He rates the pain at 9 out of 10, on a pain scale, with 10
being the worst pain, and he tells you that it is much worse when his bed sheets rub
across the toe. His past medical history is significant for gastroesophageal reflux disease
for which he takes omeprazole, and he was recently diagnosed with mild hypertension
for which he was started on hydrochlorothiazide. His blood pressure is 125/85 mm Hg,
pulse is 82/min, and respirations are 18/min. He has swelling and erythema over the first
metatarsophalangeal (MTP) joint of the left foot. The remainder of his examination,
including other joints is entirely normal. Laboratory studies show a normal complete
blood count, uric acid 12.4 mg/dl, and creatinine 0.9 mg/dl. An arthrocentesis is
performed which shows negatively birefringent crystals. The most appropriate
management for this patient is
A. allopurinol 100 mg orally once daily then a follow up uric acid level in 1 month
B. ibuprofen 600 mg orally every 8 hours for 4 weeks and start allopurinol 100 mg
once daily as soon as symptoms have resolved. Follow up uric acid level in 1 month
47
C. ibuprofen 600 mg orally every 8 hours until symptoms resolve and change his
antihypertensive agent. Follow up uric acid level in 1 month
D. no treatment is necessary for this self-limited condition
E. probenecid 250 mg orally once daily then follow up uric acid level in 1 month
Explanation:
The correct answer is C. This patient is presenting with podagra, the term applied to
acute gouty arthritis of the first MTP. This is a common disease associated with
elevated uric acid levels in the blood, and typically seen in elderly individuals. One of
the most common predisposing factors is the recent institution of a thiazide diuretic.
This impairs the renal excretion of uric acid, elevating their blood levels. Many other
drugs are associated with hyperuricemia and it can be idiopathic. He should be treated
with ibuprofen and his antihypertensive agent should be changed.
The main tenets of treatment are to look for underlying causes, and then
symptomatically treat the acute attack. If no predisposing, and alterable factors can be
found, it is often helpful to start the patient on allopurinol to prevent future attacks. It is
important, however, not to start allopurinol early in an acute attack, particularly, without
an anti-inflammatory drug in combination (choice A). This can actually exacerbate the
patient's symptoms.
Ibuprofen 600 mg orally every 8 hours for 4 weeks and starting allopurinol 100 mg once
daily as soon as symptoms have resolved, with follow up of uric acid level within 1
month (choice B) is not the most appropriate management for this patient. Even though
this is a very typical scenario in the treatment of an acute gouty attack, given the fact
that the patient was recently started on hydrocholorothiazide, it is reasonable to try
changing this medicine first, rather than adding another medication (allopurinol) to his
regimen.
It is true that an acute gouty attack is often self-limited, (choice D). However, it is not
appropriate to let the patient suffer pain any longer than he has to. Non-steroidal antiinflammatory drugs such as ibuprofen will not only help with symptoms, but they will
also shorten the duration of the attack.
Probenecid (choice E) is another drug used in the long-term treatment of gout. It
actually increases the excretion of uric acid from the kidneys. 24-hour uric acid
excretion studies can be performed to identify patients who are so called
"underexcretors". They may be better served by treatment with this medication rather
than allopurinol. In either case, it is not the best answer in this question for the reasons
described above.
A 37-year-old woman comes to the office because of a 3-month history of
"tiredness". She says that she has not felt like herself for "quite some time
now" but this fatigue is making it difficult to just get out of bed. She has been
calling in sick to work a couple of times and week and her supervisor
recommended that she "seek help." She has no other symptoms, does not
have any chronic medical conditions, does not take any medication, and has
not recently suffered a concussion. She denies severe psychological stress.
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Her temperature is 37.2 C (99.0 F), blood pressure is 110/70 mm Hg, pulse is
65/min, and respirations are 15/min. Her physical examination is
unremarkable. A complete blood count is normal. The most appropriate next
step is to
A. order a biochemical profile
B. order a chest x-ray
C. prescribe fluoxetine
D. reassure her that this will pass and schedule a follow-up visit in 1
week
E. refer her to a psychiatrist
Explanation:
The correct answer is A. The initial evaluation of a patient with fatigue
includes a thorough history and physical examination, a complete blood
count, and a biochemical profile. These will evaluate the patient for causes
of fatigue such as anemia, uremia, diabetes mellitus, adrenal insufficiency,
hypokalemia, hyponatremia, and hepatitis. If these tests are negative,
thyroid function tests and the evaluation for an infection and an occult
malignancy are indicated. If all studies are negative, a nutritional deficiency,
depression, a chronic viral infection, or chronic fatigue syndrome should be
considered. Even if chronic fatigue syndrome is suspected, routine
laboratory studies must be performed to exclude other causes of her
symptoms.
A chest x-ray (choice B) is used to evaluate a cardiopulmonary process.
Since this patient does not have symptoms that seem directly related to
these systems, a chest x-ray is not the most appropriate next step. It may be
indicated in the future because fatigue may be associated with
cardiopulmonary processes, but a biochemical profile should be ordered
next.
Fluoxetine (choice C) is used to treat depression and while it is possible that
this patient is depressed, she requires an evaluation with laboratory studies
for her fatigue. She does not complain of any other symptoms of depression,
such as difficulty sleeping, change in concentration, guilt, worthlessness,
and suicidal ideation.
Reassurance and a scheduled follow-up visit in 1 week (choice D) is
inappropriate. An evaluation for her fatigue is indicated because a 3-month
history of "tiredness" is not normal.
Referring her to a psychiatrist (choice E) may be indicated in the future, but
at this time she requires an evaluation for fatigue.
A previously healthy 21-year-old woman comes to the local college clinic because of a
headache and low-grade fevers. She is sent home with acetaminophen and advised to
49
return if she does not improve. Approximately three hours later her roommate calls 911
reporting that her friend is unconscious and not arousable. On arrival the paramedics
find a lethargic, febrile female lying on the floor and unresponsive. The patient is
stabilized and she is rushed emergently to the local hospital where an abdominal CT
scan shows bilateral adrenal hemorrhages. The patient is transported to the intensive
care unit where a pulmonary artery catheter is inserted via a right internal jugular vein.
Her temperature is 39.3 C (102.8 F), blood pressure is 85/40 mm Hg, and pulse is
140/min. An electrocardiogram demonstrates sinus tachycardia. Her extremities are
warm to the touch and appear pink. A cardiac output (CO), systemic vascular resistance
(SVR), pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP)
are obtained. The data acquired from her PA-line is most likely to be
A. CO 5.0 L/min, SVR 800 dynes-sec/cm5, PCWP 12 mm Hg, CVP 4 mm Hg
B. CO 9.5 L/min, SVR 210 dynes-sec/cm5, PCWP 8 mm Hg, CVP 6 mm Hg
C. CO 2.3 L/min, SVR 1500 dynes-sec/cm5, PCWP 30 mm Hg, CVP 10 mm Hg
D. CO 3.0 L/min, SVR 1500 dynes-sec/cm5, PCWP 8 mm Hg, CVP 1 mm Hg
E. CO 9.5 L/min, SVR 1210 dynes-sec/cm5, PCWP 12 mm Hg, CVP 6 mm Hg
Explanation:
The correct answer is B. The patient likely has septic shock that is characterized by
high cardiac output, low systemic resistance, and a relatively normal contractile function
(PCWP) and filling pressures (CVP).
CO 5.0 L/min, SVR 800 dynes-sec/cm5, PCWP 12 mm Hg, CVP 4 mm Hg (choice A) is
a profile of a normal, healthy person.
CO 2.3 L/min, SVR 1500 dynes-sec/cm5, PCWP 30 mm Hg, CVP 10 mm Hg (choice C)
is a profile of cardiogenic shock. This patient has a depressed cardiac output, a
markedly elevated PCWP reflecting failure, and an appropriately high peripheral
vasoconstrictive response to maintain blood pressure.
CO 3.0 L/min, SVR 1500 dynes-sec/cm5, PCWP 8 mm Hg, CVP 1 mm Hg (choice D)
reflects hypovolemic shock with a low output, an appropriately high peripheral
resistance but very low filling pressures.
CO 9.5 L/min, SVR 1210 dynes-sec/cm5, PCWP 12 mm Hg, CVP 6 mm Hg (choice E)
is representative of a healthy person undergoing vigorous exercise, with augmented
cardiac output, normal systemic resistance and filling pressures.
A 19-year-old woman is brought to the emergency department by her parents because
of confusion. Her parents tell you that over the last 2 weeks the patient has had an 11pound weight loss and fatigue. She had been constantly using the bathroom but they
assumed it was only because she seemed to be drinking huge amount of liquids. Her
parents reported no previous medical problems in her history. Her last normal menstrual
period ended 3 days ago. You notice a stuporous white female who appears thin and in
moderate distress. Her temperature is 38.0 C (100.4 F), blood pressure is 90/40 mm Hg,
pulse is 115/min, and respirations are 30/min. Physical examination shows dry mucous
50
membranes, sunken eyes, and pale appearance. Her breath has a noticeably fruity odor.
Her heart is tachycardic and regular without any murmurs. Her abdomen is soft, nondistended, with decreased bowel sounds and some mild diffuse tenderness. Her
extremities are cool with weak pulses. The most likely diagnosis will be established with
A. a CT scan of the abdomen and pelvis
B. an electrocardiogram
C. serum glucose and electrolytes
D. a urine drug screen
E. a urine pregnancy test
Explanation:
The correct answer is C. All of the answer choices would be important in the initial
evaluation of this patient but only serum glucose and electrolytes would yield the
diagnosis. This patient likely has diabetic ketoacidosis. Clues to this diagnosis included
the "fruity" odor on her breath, history of polyuria and polydipsia, recent weight loss,
and dehydration. These laboratory studies will most likely reveal an anion gap acidosis
with an elevated glucose.
A CT scan of the abdomen and pelvis (choice A) would help determine if there are and
intraabdominal infections (i.e., appendicitis, abscess, etc.) but this is unlikely to be the
cause of this patient's illness. This patient has a benign abdominal exam, which would
further support the suspicion that there is not a severe abdominal infection.
Finally, an electrocardiogram (choice B) would be important to evaluate any changes
consistent with ischemia, arrhythmia, or electrolyte imbalances but would not give us a
diagnosis in this patient. The serum glucose and electrolytes should be ordered
immediately because of the physical findings. The EKG can be performed as soon as
these are drawn.
A urine drug screen (choice D) is also important in the initial workup of the stuporous
patient since drug overdose would certainly be in the differential diagnosis.
A urine pregnancy test (choice E) is an important test to perform in all women of
childbearing age with abdominal pain. Her last normal menstrual period ended 3 days
ago, so it is unlikely that she is pregnant. Although it would not give us the diagnosis in
this case, it should be included in initial screening to rule out an ectopic pregnancy.
51