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A 55-year-old African-American male comes to the office for a routine follow-up visit. His past medical history
is significant for type 2 diabetes mellitus (OM). hypertension for the last 5 years. and an acute myocardial
infarction 2 years ago. His mother died of a heart attack at the age of 72 years. and his father died in a motor
vehicle accident at the age of 42 years. He has no siblings. He is currently on glyburide. captopril and baby
aspirin. He is very compliant with his diet and medication. His glycemic control was very good until a few
months ago. when he noticed that his blood sugar levels were running high. This morning. his fingerstick
reading was 200 mg/dl. He weighs 188 lbs and is 5'8" tall. His physical examination is otherwise
unremarkable. His bloodwork done three days ago showed blood urea nitrogen of 14 mg/dl and a creatinine
level of 1.0 mg/dl. His HBA1c one month ago was 8.0%. Which of the following is the most appropriate next
step in management?

r A. Discontinue captopril because it is known to produce diabetogenic state.

r B. Discontinue captopril since glyburide efficacy is reduced with simultaneous usage of captopril.
r C. Start the patient on human insulin 70/30.
r D. Add metformin to achieve better glycemic control.
r E. Add pioglitazone to achieve better glycemic control.

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A 78-year-old female is being evaluated for recent weight loss and fatigue. Laboratory tests reveal abnormal
thyroid function. She begins treatment with a single agent, but soon after is hospitalized with new onset atrial
fibrillation and hand tremor. Which of the following treatments had she most likely received?

r A. Propylthiouracil
r B. lopanoic acid
r C. Radioactive iodine
r D. Propranolol
r E. Prednisone

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A 45-year-old unconscious male is broughtto the emergency room. His airway is secured. oxygen is
administered. and his vitals are as follows Temperature 36 4C(97 .SF); PR 102/min; BP 90/65 mm of Hg;
RR 27/min. An IV line is secured and blood and urine samples are drawn. Lab results are as follows:
Blood urea nitrogen
Calcium
ALT
AST
Ammonia
PT
APTT
Amylase
Glucose
Sodium
Potassium
Chloride
Bicarbonate

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PH
PaC02
Pa02

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7.19
25 mm Hg
80 mm Hg

Blood and urine are positive for ketones. A diagnosis of diabetic ketoacidosis (DKA) is made and IV infusion of
normal saline and regular insulin are started. What will be a most reliable index for monitoring the response to
treatment?

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40 mg/dl
9.1 mg/dl
50 U/1
60 U/1
15 micro-mol/1 (Normal is 9-33 micro-mol/1)
13 sec
30 sec
1DO U/1
400 mg/dl
134 meq/1
5.2 meq/1
97 meq/1
12 meq/1

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A. Urine glucose
B. Serum osmolality
C. Serum ketones
D. Urine ketones
E. Serum anion gap

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A 35-year-old white female presents with complaints of weight gain. lethargy and constipation for the last 2
months. She also complains of cold intolerance and oligomenorrhea. She is not taking any medication. She
is a non-smoker, and does not drink alcohol. Her pulse is 67/min, and blood pressure is 130/90 mm Hg. She
is afebrile. Her hands are dry and cold. There is a non-tender, diffuse rubbery enlargement of the thyroid
gland without any discrete nodularity. She does not have exophthalmos, lid lag or lid retraction. Labs show
decreased serum T4 levels. elevated serum TSH levels and positive anti-thyroperoxidase (TPO) antibodies.
Which of the following complications may develop in this patient?

r A. Lymphoma of the thyroid

r B. Papillary carcinoma of the thyroid
r C. Follicular carcinoma of the thyroid
r D. Anaplastic carcinoma of the thyroid
r E. Medullary carcinoma of the thyroid

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A 37-year-old white female presents with galactorrhea and amenorrhea for the past 7 months. She denies
any headaches. visual problems. vaginal dryness or dyspareunia. She is married. has two children. and
remarks that her family is "complete." She does not use tobacco, alcohol or drugs. Her blood pressure is
120/80 mmHg, pulse is 72/min, temperature is 36'7C (98F) and respirations are 14/min. Visual field testing is
within normal limits. Pregnancy test is negative. Her serum prolactin level is 150 ng/ml. Pituitary MRI shows
a 6 mm pituitary adenoma. Which of the following is the most appropriate next step in the management of
this patient?

r A. Surgery
r B. Treatment with cabergoline
r C. Treatment with estrogens
r D. Radiotherapy
r E. Monitoring by serum prolactin and MRI

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A 55-year-old Caucasian male presents to the office for a routine check-up. He has no present complaints.
His past medical history is significant for a long history of hypertension. He does not smoke or consume
alcohol. His current medications are enalapril and hydrochlorothiazide. His blood pressure is 140/90 mm Hg
and heart rate is 80/min. Physical examination reveals a moderately overweight man (BMI 27 kg/m2) with a
waist circumference of 41 inches. The laboratory studies show:

Fa sting blood glucose

Total cholesterol
LDL cholesterol
Triglycerides

112 mg/dl
220 mg/dl
140 mg/dl
240 mg/dl

Which of the following is the most important pathogenic factor for this patient's condition?

r A. Impaired secretion of insulin

r B. Low absolute values of insulin
r C. Insulin resistance
r D. Sympathetic hyperactivity
r E. Insulin-mediated vasodilatation

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A 40-year-old Caucasian female presents to the office complaining of weakness. insomnia. palpitations. and
weight loss. Her past medical history is insignificant. Her blood pressure is 130/65 mmHg and heart rate is
11 0/min. Physical examination reveals a fine tremor of her outstretched hands and lid lag. Biochemical
testing confirms the suspected diagnosis of Graves' disease. The various treatment options. including
radioiodine therapy, are discussed with the patient. Which of the following is the most common side effect of
radioiodine therapy?

r A. Thyroid carcinoma
r B. Increased ophthalmopathy
r C. Leukemia
r D. Hypoparathyroidism
r E. Hypothyroidism

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A 31-year-old woman presents with palpitations and weight loss. Her past medical history is insignificant. Her
family history is unremarkable. She does not smoke cigarettes or drink alcohol. She is married and has three
children. Her last delivery was four years ago. Her blood pressure is 140/90 mmHg. pulse is 102/min.
temperature is 36.7C (98F) and respirations are 20/min. Her eye examination is unremarkable. Thyroid
examination reveals a 2 x 2 em left-sided thyroid nodule. Her T3 and T4 are elevated, and TSH is
undetectable. Radioactive iodine scan shows uptake only in the left thyroid nodule. Uptake in the rest of the
thyroid is markedly reduced. Which of the following is the most likely diagnosis?

r A. Hashimoto's thyroiditis
r B. Toxic adenoma
r C. Graves' disease
r D. Toxic multinodular goiter
r E. Painless thyroiditis

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A 45-year-old female comes to the office for the evaluation of excessive hair growth over her face and body.
Her hirsutism rapidly developed over a period of 3 months. She underwent bilateral tubal ligation 4 years ago.
Her menstrual cycles were regular in the past, but for the last 3 months. she has not had a menstrual period.
She denies any hot flashes or vaginal discomfort. On physical examination. her height is 5'2" ( 157 em) and
weight is 140 lbs (63 .5 kg). A large amount of coarse terminal hair is noted on her face. chest and lower
abdomen. She appears masculine and has an enlarged clitoris. There is significant temporal balding. Which
of the following is the most appropriate next step in management?

r A. Serum LH and FSH

r B. Serum testosterone and DHEAS
r C. CT scan of abdomen
r D. Serum 17- hydroxyprogesterone levels
r E. Selective adrenal and ovarian vein samplings

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A 40-year-old asymptomatic male comes to the office for a routine physical examination. His serum
chemistry panel shows:
Sodium
Potassium
Bicarbonate
Chloride
Calcium
Albumin
Phosphorus
Creatinine
25-hydroxy vitamin D

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140 mEq/L
4.0 mEq/L
25 mEq/L
101 mEq/L
11 .8 mg/dl
4.0 g/dl
2.2 mg/dl
1.3 mg/dl
38 ng/ml

24-hour urine collection reveals a calcium level of 250 mg and creatinine level of 1.7 g. Serum parathyroid
hormone (PTH) level is increased. Dual energy X-ray absorptiometry (DEXA) shows normal bone mineral
density. Neck examination reveals no masses. What is the most appropriate next step in the management of
this patient?

r
r
r
r
r

A. Bisphosphonate therapy
B. CT scan of the chest, abdomen, and pelvis
C. Imaging of the neck with a sestamibi scan
D. Loop diuretics
E. Medical surveillance

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A 50-year-old male presents with polyuria and polydipsia. He has smoked 1 pack of cigarettes daily for the
past 30 years. He denies having any past medical problems. His mother and one maternal uncle are
diabetic. His height is 5'8" (172 em), weight is 180 lbs (81.6 kg), temperature is 37C (98.6F), pulse is
75/min, blood pressure is 150/90 mm Hg, and respirations are 15/min. Examination of all the systems is
unremarkable. Chemistry panel shows:
Sodium
Potassium
Bicarbonate
Blood glucose
BUN
Creatinine

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140 mEq/L
4.1 mEq/L
26 mEq/L
21 0 mg/dl
12 mg/dl
0.9 mg/dl

The patient is diagnosed with type 2 diabetes mellitus. He is advised exercise and dietary modification. He
is referred to an ophthalmologist and appropriately screened for diabetic retinopathy. What is the most
sensitive test to screen for nephropathy in this patient?

r
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r
r
r

A. Creatinine clearance
B. Dipstick testing of urine for protein
C. Random urine for microalbumin/creatinine ratio
D. Renal ultrasound
E. Oral glucose tolerance test

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A 65-year-old Hispanic male comes to the office for a routine medical check up. He has a history of diabetes
for the past twenty years, and hypertension for the past ten years. His daily medications include insulin and
ramipril. He was diagnosed with nonproliferative diabetic retinopathy at his last ophthalmologic visit. Reports
from his previous laboratory studies show microalbuminuria. A detailed neurological examination is
performed to check for any neuropathy. Which of the following is the most common type of neuropathy found
in diabetics?
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r A. Proximal motor neuropathy

r B. Autonomic neuropathy
r C. Mononeuropathy multiplex
r D. Symmetrical distal polyneuropathy
r E. Mononeuropathy

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A 60-year-old female presents with transient loss of consciousness. She appears lethargic and confused.
She also complains of hemoptysis and weight loss of 10 lbs (4 .5kg) over a period of 2 months. She has
smoked one pack of cigarettes daily for the last 40 years. Her temperature is 37.0C (98.6F), pulse is 75/min,
blood pressure is 11 0/70, and respirations are 16/min. Her mucus membranes are moist. There is no jugular
venous distention. Her neurological examination is non-focal, and cardiovascular examination is unrevealing.
There is no ankle edema or ascites. Serum studies show:
Sodium
Potassium
Bicarbonate
Blood glucose
BUN

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115 mEq/L
3.7 mEq/L
22 mEq/L
1DO mg/dl
10.0 mg/dl

Serum osmolality is 250 mOsm/Kg, and urine osmolality is 500 mOsm/Kg. Urine sodium concentration is 40
mEq/L. Chest x-ray shows a mass in the right hilar region. What is the most appropriate next step in the
management of this patient?

r
r
r
r
r

A. Normal saline
B. Loop diuretics
C. Water restriction
D. Hypertonic saline
E. Demeclocycline

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A 15-year-old female is brought to the emergency department with confusion, rapid breathing and abdominal
pain. She had been in her usual state of health until three days ago, when she developed runny nose, dry
cough and fever. She subsequently developed urinary frequency, progressive fatigue, and somnolence. On
physical examination, her mucous membranes are dry and there is abdominal tenderness without rebound.
Laboratory findings are given below.
Hematocrit
WBC count
Sodium
Potassium
Bicarbonate

42%
13,000/mm3
145 mEq/1
5.7 mEq/1
9 mEq/1

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

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A. Liver glucose production

B. Blood renin activity
C. Circulating free fatty acids
D. Total body potassium stores
E. Urine solute excretion
F. Hypothalamic vasopressin production

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A 23-year-old man presents to your office complaining of occasional headaches, muscle weakness and
fatigue. He also describes periodic numbness of his extremities. The symptoms started 6 months ago and
have gradually progressed. His past medical history is insignificant. He is not taking any medication. His blood
pressure is 165/1 04 mm Hg and heart rate is 80/min. His physical examination is within normal limits. Which
of the following laboratory findings is the most specific for the patient's condition?

r A. Low serum potassium level

r B. High serum sodium level
r C. Metabolic alkalosis
r D. Low plasma renin activity
r E. High aldosterone/renin ratio

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A 28-year-old avid mountain climber and his friend are vacationing in Andes, South America. During their
mountain climbing expedition, the pair somehow manages to get lost. It has been over 16 hours since their
food supply ran out. Their glycogen stores are becoming depleted, and their bodies are beginning to utilize the
process of gluconeogenesis. Which of the following intermediates is alanine being converted into during this
process?

r A. Pyruvate
r B. Glycerol-3-phosphate
r C. Transketolase
r D. Citrate
r E. Lactate

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A 25-year-old woman comes into the office with a three-month history of weight loss, irritability, insomnia, and
palpitations. Her past medical history is insignificant. She is nottaking any current medications and denies
drug abuse. Her blood pressure is 155/70 mmHg and heart rate is 11 0/min. Physical examination reveals lid
retraction, fine tremor of the hands, and increased neck circumference. The most probable cause of
hypertension in this patient is

r A. Hyperdynamic circulation
r B. Increased peripheral vascular resistance
r C. Sodium retention
r D. Decreased vascular compliance
r E. Increased intravascular volume

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A 45-year-old male, found unconscious, is broughtto the emergency room. His airway is maintained, and
oxygen is administered. His temperature is 39 .DC ( 102 .5F), pulse is 102/min, blood pressure is 90/65 mm of
Hg and respirations are 23/min. Intravenous access is secured and blood and urine samples are drawn. Lab
results are as follows:

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134 mEq/L
5.9 mEq/L
101 mEq/L
22 mEq/L
110 mg/dl
1000 mg/dl
10.2 mg/dl

Amylase
Aspartate aminotransferase
Alanine aminotransferase
Ammonia

100 U/L
15 U/L
17 U/L
15 micro-moi/L
(Normal is 9 -33 micro-moi/L)
13 sec
30 sec

PT
APTT
Arterial blood gases:
PH
PaC02
Pa02

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Sodium
Potassium
Chloride
Bicarbonate
Blood urea nitrogen
Glucose
Serum calcium

740
38 mm Hg
90 mm Hg

Which of the following is the most appropriate initial infusion you should order for this patient?

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A. Normal saline
B. 045% saline
C. 5% dextrose

D. Regular insulin
E. Potassium

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A 33-year-old Caucasian female presents with complaints of polyuria and polydipsia of recent onset. She
prefers cold beverages to quench her thirst. Her pulse is 85/min, blood pressure is 11 0/70 mm Hg, and
respirations are 15/minute. She is afebrile. The lab results are:
Hb
WBC
Platelets
Blood glucose
Serum Na
Serum K
Bicarbonate
BUN
Serum creatinine
Serum uric acid
Serum osmolality
Urine osmolality

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14 g/dl
6,000/cmm
280 ,000/cmm
11 0 mg/dl
145 mEq/L
4.1 mEq/L
26 mEq/L
17 mg/dl
1.0 mg/dl
10 mg/dl
302 mOsml/kg
180 mOsml/kg

Which of the following is most consistent with this patient's findings?

r
r
r
r
r

A. Primary polydypsia
B. Primary aldosteronism
C. Osmotic diuresis
D. SIADH
E. Diabetes insipidus

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A 45-year-old white female presents with complaints of diffuse body pains and muscle weakness. She was
diagnosed with celiac sprue several years ago. She admits to non-compliance with her gluten-free diet. After
the appropriate evaluation, she is given a diagnosis of osteomalacia secondary to vitamin D deficiency. She
is started on vitamin D, calcium and phosphate, and begins to improve with this treatment. Which of the
following is most likely to occur with vitamin D deficiency?

r A. Defective mineralization of bone

r B. Defective mineralization of bone and cartilage
r C. Disordered skeletal remodeling
r D. Defective formation of collagen
r E. Low bone mass with normal mineralization

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A 60-year-old asymptomatic man presents to your office for a routine check-up. He has a 10-year history of
type 2 OM, and a 12-year history of hypertension. His current medications include low-dose glyburide and a
low-dose thiazide diuretic. His blood pressure is 140/90 mm Hg and heart rate is 65/min. Physical
examination shows a soft ejection systolic murmur at the base of the heart. Ophthalmoscopic evaluation
reveals no abnormalities. ECG recorded 6 months ago showed left ventricular hypertrophy and non-specific
ST segment and T-wave abnormalities. His recent fasting glucose level was in the range of 120 to 150
mg/dl, and HbA1c was 7.1 % (normal < 6%). 24-hour urine collection reveals microalbuminuria. Which of
the following is the best measure to slow end-organ damage in this patient?

r A. Increase the dose of glyburide

r B. Increase the dose of thiazide diuretic
r C. Switch to insulin
r D. Add ACE inhibitor
r E. Add beta-blocker

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A 36-year-old woman comes to the physician for a routine health examination. She has no complaints or
previous medical problems and takes no medications. She does not use tobacco, alcohol, or illicit drugs. Her
menstrual cycles are regular. The patient is an architect at a local construction firm. She has had no
exposure to excessive radiation in the past. Her family history is negative for thyroid problems. Her
temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 16/min.
Examination of the neck shows a 2x2 em, discrete, nontender, firm, and mobile nodule in the left thyroid lobe
without cervical lymphadenopathy. The remainder of the examination is within normal limits. Which of the
following is the most appropriate initial step in evaluation of this patient?

r A. Computed tomography scan of the neck

r B. Fine-needle aspiration biopsy
r C. Measurement of thyroid-stimulating hormone and thyroid ultrasound
r D. Radionuclide scan
r E. Serum anti-thyroid peroxidase antibodies and thyroglobulin

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A 56-year-old woman presents to the clinic with a 7-month history of headache and visual disturbance. Her
past medical history is unremarkable. She is currently not taking any medications. She admits to smoking a
pack of cigarettes daily for the last 15-years, and does not drink. On visual field examination, there is a small
field defect noted in both eyes. MRI scan shows a pituitary tumor. Which of the following is the most
common type of pituitary tumor?

r A. Thyrotroph adenoma
r B. Gonadotroph adenoma
r C. Corticotroph adenoma
r D. Lactotroph adenoma
r E. Somatotroph adenoma
r F. Craniopharyngioma

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A 55-year-old woman comes to the clinic because of muscle weakness in both lower extremities for the past
1 month. She has slight difficulty getting up from a chair and weakness and cramping in her legs after walking
a short distance. The weakness and cramping improve with rest. She also complains of intermittent muscle
aches at night and sometimes during the day. Her other medical problems include hypertension, which is
treated with lisinopril. She does not use tobacco, alcohol, or illicit drugs. Her blood pressure is 140/80 mm
Hg, pulse is 64/min, and respirations are 14/min. Examination shows decreased muscle strength in both
lower extremities and sluggish ankle reflexes bilaterally. Laboratory tests show an elevated serum creatine
kinase (CK) level. Which of the following is the most appropriate next step in management?

r A. Serum lisinoprillevels
r B. Blood sugar levels
r C. SerumTSH
r D. Muscle biopsy
r E. Electromyogram

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A 35-year-old female presents to the emergency department with a 3D-minute history of severe headache,
palpitations, abdominal pain, nausea, and vomiting. She had similar episodes twice during the last month, but
those were not so severe and resolved spontaneously in 30-40 minutes. She visited a doctor recently, and
hypertension with elevated urinary vanillylmandelic acid level was diagnosed. She is not taking any
medications, and denies substance abuse. Her blood pressure is 200/130 mmHg and heart rate is 130/min.
She appears frightened. Physical examination reveals hand tremors and excessive sweating. Slow
intravenous infusion of propranolol is started while waiting for the routine labs. What is the most probable
reaction to the treatment given to the patient?

r A. Blood pressure will slowly decrease

r B. Blood pressure will rapidly decrease
r C. Heart rate will increase
r D. Heart rate will not change
r E. Blood pressure will rapidly increase

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A 60-year-old male comes to the office due to edema of his face and ankles of tvvo weeks duration. He denies
any chest pain or breathlessness. He is a known diabetic for the past 15 years. His diabetes is being
managed with exercise, dietary modification and glyburide. His glycosylated hemoglobin (HbA1C) level one
month ago was 7.5%. His temperature is 37.0C (98.6F), pulse is 75/min, blood pressure is 146/87 mm Hg,
and respirations are 15/min. Examination is unremarkable, except for bilateral pitting edema around the
ankles and periorbital edema. Lab results show:
Serum sodium
Potassium
Bicarbonate
Blood glucose
Blood urea nitrogen
Serum creatinine
Total cholesterol

140 mEq/L
4.3 mEq/L
20 mEq/L
120 mg/dl
37 mg/dl
24 mg/dl
300 mg/dl

EKG is normal. 24 hour urine collection shows 3.7 g protein/day. To alter the course of this patient's diabetic
nephropathy, what is the most appropriate next step in management?

r
r
r
r
r

A. Intensive glycemic control

B. Intensive blood pressure control
C. Very low protein diet
D. Aggressive lipid management
E. Aspirin therapy

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A 34-year-old Caucasian female comes to the emergency department and complains that her heart is "racing
out of control." She began to feel this way only this morning. She denies any chest pain or shortness of
breath. Over the past few months, she has unintentionally lost 10 pounds. Her past medical history is
significant for panic attacks, but she claims she has not had an attack for over 10 years. She is very
concerned because her father died of a heart attack at the age of 40. The EKG reveals sinus tachycardia at a
rate of 120/min. The initial labs show
CBC
Hb
Ht
MCV
Platelet count
Leukocyte count
Neutrophils
Eosinophils
Lymphocytes
Monocytes

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Serum

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Serum Na
Serum K
Chloride
Bicarbonate
BUN
Serum Creatinine
Calcium
Blood Glucose

139 mEq/L
4.2 mEq/L
100 mEq/L
25 mEq/L
10 mg/dL
1.0 mg/dL
9.1 mg/dL
102 mg/dL

TSH
Free T4

< 0.1 microU/mL

4.6 ng/dL (N 0.9-24)

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12.9g/dL
39%
88 fl
200,000/cmm
8,500/cmm
67%
1%
24%
8%

Which of the following is the best immediate step to control this patient's symptoms?
r

n ...............~.-.; ................ a

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Hb
Ht
MCV
Platelet count
Leukocyte count
Neutrophils
Eosinophils
Lymphocytes
Monocytes

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12.9g/dL
39%
88 fl
200 ,000/crnrn
8 ,500/crnrn
67%
1%
24%
8%

Serurn

21

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concerned because her father died of a heart attack atthe age of 40. The EKG reveals sinus tachycardia at a
rate of 120/rnin. The initial labs show

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Serurn Na
Serurn K
Chloride
Bicarbonate
BUN
Serurn Creatinine
Calciurn
Blood Glucose

139 rnEq/L
4.2 rnEq/L
100 rnEq/L
25 rnEq/L
10 rng/dL
1.0 rng/dL
9.1 rng/dL
102 rng/dL

TSH
Free T4

< 0.1 rnicroU/rnL

4.6 ng/dL (N 0.9-24)

Which of the following is the best irnrnediate step to control this patient's syrnptorns?

r
r
r
r
r

A. Propylthiouracil
B. Subtotal thyroidectomy
C. Alprazolarn

D. Radioactive Iodine
E. Propranolol

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A 40-year-old female presents with altered mental status and confusion. Last year, she was diagnosed with
rheumatoid arthritis, for which she is currently using indomethacin and methotrexate. Her temperature is 37.0
C (98.6F), pulse is 75/min, blood pressure is 110/70, and respirations are 15/min. She is disoriented and
irritable. Mucus membranes are moist. There is no jugular venous distention. Lungs are clearto
auscultation. Abdomen is soft, nontender and not distended. There is no peripheral edema. Serum
chemistry reveals:
Sodium
Potassium
Bicarbonate
Blood glucose
BUN
Uric acid

122 mEq/L
3.7 mEq/L
22 mEq/L
90 mg/dL
9.0 mg/dL
3.0 mg/dL

Serum osmolality is 265 mOsm/kg, while urine osmolality is 500 mOsm/kg. What is the most likely cause of
this patient's hyponatremia?

r
r
r
r
r

A. Mineralocorticoid deficiency
B. Advanced renal failure
C. Nephrotic syndrome
D. Syndrome of inappropriate ADH secretion
E. Diabetes insipidus

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A 49-year-old man comes to the physician complaining of 3 months of progressively worsening headaches.
He also reports diffuse joint pain, pain on the lateral half of his right hand, difficulty getting his wedding ring off
due to finger swelling, and difficulty gripping objects with his right hand. He has poorly controlled hypertension
despite being compliant with medications, a very low-salt diet, and regular exercise. His temperature is 36.7
C (98 F), blood pressure is 146/98 mm Hg, pulse is 90/min, and respirations are 14/min. His facial features
appear coarse and significantly different when compared to his driver's license photograph taken 3 years ago.
His palms are sweaty and have a doughy feel. His skin is oily. Multiple skin tags are noted, particularly around
his neck area. Tapping the ventral part of the right wrist produces shooting pain on the lateral side of his right
hand. Which of the following is the best next step in making the diagnosis?

r A. Growth hormone level

r B. Magnetic resonance imaging of the pituitary gland

20

r C. Measuring growth hormone level following an oral glucose load

21

r D. Measuring insulin-like growth factor-1 level

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r E. Thyrotropin-releasing hormone stimulation test

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A 22-year-old female presents with complaints of heat intolerance, sweating and palpitations. She also
reports menstrual irregularities, increased appetite and diarrhea. Her pulse is 102/min and regular, blood
pressure is 116/80 mm Hg, temperature is 37 .2C (99F), and respirations are 14/min. Physical examination
reveals a diffusely enlarged, nontender thyroid gland. TSH level is 0.05 mUlL. Free T4 and T3 levels are
elevated. Radioactive iodine uptake at 24 hours is 50 percent. Thyroid stimulating immunoglobulins are
present. She is started on propylthiouracil 300 mg daily in three divided doses. After two weeks, she returns
and complains of a sore throat. Her pulse is 98/min and regular, temperature is 38.6C (1 01.5F), blood
pressure is 115/76 mm Hg, and respirations are 15/min. The soft palate, pharynx, and tonsils are red and
swollen What is the most appropriate next step in the management of this patient?

r A. Add propranolol
r B. Increase propylthiouracil dose
r C. Stop propylthiouracil
r D. Throat culture
r E. Oral penicillin
r F. Acetaminophen

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A 65-year-old man presents with a 1-year history of impotence and decreased libido. He has a 15-year history
of type 2 diabetes mellitus, which is controlled with diet. He denies any cardiac problems, visual changes or
symptoms of neuropathy. The genitourinary examination reveals decreased testicular size and
absent gynecomastia. The rest of the physical examination is unremarkable. The laboratory report shows:
Hemoglobin A 1c
Testosterone

5%
2.0 ng/dl (Normal 3 -1 0 ng/dl)

LH
FSH

3 U/L
4 U/L

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

r
r
r
r
r

A. Insulin therapy
B. Angiography of the deep arteries of the penis
C. Doppler ultrasonography of penile blood flow
D. Measure the serum prolactin level

E. Measure the serum estradiol level

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A 21-year-old man with type 1 diabetes mellitus presents to the emergency department with complaints of
abdominal pain, nausea and vomiting. His temperature is 36 .DC (97 .OF), pulse is 11 0/min, blood pressure is
102/60 mm Hg, and respirations are 26/min. Lungs are clearto auscultation. Abdomen is soft, non-tender
and non-distended. Chemistry panel shows:
Sodium
Potassium
Chloride
Bicarbonate
Blood glucose

130 mEq/L
5.2 mEq/L
90 mEq/L
10 mEq/L
450 mg/dl

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

r A. Normal saline and regular insulin

r B. 0.45% saline and regular insulin
r C. Normal saline and NPH insulin
r D. 5% dextrose and NPH insulin
r E. Sodium bicarbonate

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A 46-year-old woman with a history of breast cancer comes to the physician with back pain, nausea, and
vomiting. Imaging shows several lytic lesions in the thoracic spine. Laboratory testing shows serum calcium
of 13.1 mg/dl and serum albumin of 3.4 mg/dl. Her serum parathyroid hormone level is 10 pg/ml (normal,
10-60 pg/ml). Which of the following mechanisms is most likely responsible for her hypercalcemia?

r A. Direct bone resorption by the tumor cells

r B. Ectopic parathyroid hormone production by the tumor cells
r C. Extra-renal production of calcitriol
r D. Production of parathyroid hormone-related peptide by the tumor cells

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A 60-year-old Caucasian male presents to your office complaining of decreased hearing on the right side. He
also feels that something is wrong with his head because his hat size had increased over the last two years.
His past medical history is significant for hypertension and peptic ulcer disease. His current medications are
hydrochlorothiazide and enalapril. He also takes ibuprofen for occasional headaches, and ranitidine for
infrequent episodes of heartburn. Lab tests showed increased alkaline phosphatase levels. Which of the
following is the most likely mechanism underlying this patient's condition?

r A. Increased osteoid deposition

r B. Bone demineralization
r C. Abnormal bone remodeling
r D. Fibrous replacement of the bone
r E. Abundant mineralization of the periosteum
r F. Avascular necrosis of the bone
r G. Chronic granulomatous inflammation

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A 65-year-old man comes to the physician complaining of decreased appetite, nausea, abdominal bloating,
and early satiety for the past several months. He has no heartburn or epigastric pain but does have
occasional vomiting. The patient has longstanding type 2 diabetes mellitus complicated by nonproliferative
retinopathy and has taken insulin for the last 15 years. His blood glucose readings using the home monitor
are 40-400 mg/dl. Most of the low blood glucose readings occur after meals. Which of the following would
be most helpful in treating this patient's condition?

r A. Diphenhydramine
r B. He/icobacfer pylori eradication therapy
r C. Lansoprazole
r D. Megestrol acetate
r E. Metoclopramide
r F. Ondansetron
r G. Promethazine
r H. Ranitidine

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A 48-year-old white male complains of generalized bone pain after undergoing bowel surgery for inflammatory
bowel disease. His pain is more severe at the lower spine, pelvis, and lower extremities. Examination shows
tenderness over the lower spine, pelvis, and lower extremities. Proximal muscle weakness is noted. X-rays
of the lumbar spine show decreased bone density with blurring of the spine. X-rays of the femoral neck show
pseudofractures, bilaterally. Which of the following lab abnormalities is consistent with this patient's
diagnosis?

r A. Low serum calcium, low serum phosphate, increased serum parathyroid hormone
r B. Increased serum calcium, low serum phosphate, increased serum parathyroid hormone
r C. Normal serum calcium, normal serum phosphate, normal serum parathyroid hormone
r D. Low serum calcium, increased serum phosphate, low serum parathyroid hormone

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A 50-year-old Caucasian male comes to the office for the evaluation of polyuria and polydypsia for the last tvvo
months. He also complains of weakness and fatigue. He had one episode of transient proximal muscle
weakness which lasted 30 minutes. He has a 20-pack year history of smoking. He does not drink alcohol.
His past medical and family histories are insignificant. His pulse is 78/min, blood pressure is 150/96 mm Hg
and temperature is 36.7C (98F). The rest of the examination, including the neurological examination, is
normal. Labs show:
Plasma sodium
Potassium
Serum creatinine

150 mEq/L
2.6 mEq/L
0.8 mg/dl

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

r
r
r
r
r

A. Measurement of plasma renin activity and aldosterone concentration

B. Measurement of 24 hour urinary potassium excretion
C. Aldosterone suppression testing
D.lmaging of adrenals by CT scan
E. Adrenal vein sampling

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A 24-year-old white female is brought to the emergency department (ED) by her mother due to altered mental
status. According to her mother, she suffered from viral gastroenteritis 4 days ago. Since then, she has been
on oral fluids. Over the past 2 days, her condition had been deteriorating, but she kept refusing admission to
the hospital. Her past history is not significant, except for excessive thirst, water intake and weight loss over
the past two months. Her blood pressure is 100/56 mm Hg, pulse is 120/min (regular and weak), temperature
is 37.2C (99.F), and respirations are 28/min (rapid and deep). Pulse oximetry is 94% on room air. She is
arousable and moves all her extremities. Her mucous membranes are very dry. Her neck is supple. The
chest is clear on auscultation Which of the following is the most appropriate next step in management?

r A. Obtain electrocardiogram
r B. Obtain arterial blood gases
r C. Fingerstick glucose
r D. Intubate the patient
r E. Obtain CT scan of head

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A 35-year-old white male presents with fatigue, decreased appetite, weight gain, constipation and cold
intolerance. He cannot recall any stressful event. He does nottake any medications. He is a non-smoker
and non-alcoholic. His pulse is 4 7/min and blood pressure is 145/91 mmHg. Physical examination reveals
cool, pale skin, coarse hair, and brittle nails. There is delayed relaxation of deep tendon reflexes. The thyroid
gland is normal on palpation. Laboratory studies reveal increased serum free T3 and T4 levels, and normal
serum TSH level Which of the following is the most likely diagnosis?

r A. Primary hypothyroidism
r B. Secondary hypothyroidism
r C. Subclinical hypothyroidism
r D. Generalized resistance to thyroid hormones
r E. Graves' disease

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11 PMark

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A 24-year-old Caucasian female comes to the outpatient clinic and complains of heat intolerance and
increased appetite. Her past medical history is insignificant. She denies use of over-the-counter
medications. Her pulse is 11 0/min and regular, temperature is 37 .2C (99F), and respirations are 14/min.
Swelling is noted in the front of her neck, which moves with deglutition. Lab studies show:
Total T4
Free T4
TSH

Increased
Increased
Decreased

Radioactive iodine uptake is decreased. The thyroid scan shows very low uptake of radioiodine. What is the
most likely diagnosis?

r A. Multinodular goiter
r B. Toxic adenoma
r C. Graves disease
r D. Struma ovarii
r E. Thyroiditis

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Item: 41 of 44

!il f" Mark

Q.ld: 3807 [

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A 45-year-old woman comes to the physician for a routine medical checkup. She has no complaints. She
has 20-pack-year smoking history but stopped smoking a year ago. The patient was diagnosed with
hypertension 6 months ago and has since been taking hydrochlorothiazide. Her last Pap smear 2 years ago
was normal with negative human papilloma virus screening. She received T d (tetanus and diphtheria) and
pneumovax vaccinations 5 years ago. She does not use alcohol or illicit drugs. Her mother and a maternal
uncle have type 2 diabetes. There is no history of cancer in the family. The patient's temperature is 37 C (98
F). blood pressure is 130/80 mm Hg. pulse is 80/min. and respirations are 14/min. Her body mass index is
28.3 kg/m2 . Examination is otherwise unremarkable. Which of the following is the most appropriate next step
in management of this patient?

r A. Check HbA1C levels

r B. Chest x-ray with posterior-anterior and lateral views
r C. Human papilloma virus vaccine
r D. Pap smear
r E. Pneumovax revaccination

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Item: 42 of 44

!II PMark

Q.ld: 4128 [

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A 27-year-old man is diagnosed with medullary thyroid carcinoma that is nonresectable. His past medical
history is unremarkable. He does not smoke or consume alcohol. His family history is significant for
medullary thyroid cancer and pheochromocytoma in his father but no other cancers. His examination is
otherwise within normal limits. Which of the following would have been the most effective screening method
to detect this patient's condition?

r A. Annual physical examination

r B. DNA testing
r C. Frequent self-examination of the neck
r D. Periodic serum calcium measurement
r E. Periodic stimulated serum calcitonin measurement

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Item: 43 of 44
Q.ld: 4191 [

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A 60-year-old Caucasian male presents to the office with erectile dysfunction that progressed slowly over the
last several months. He finds it difficultto obtain an erection. and has noted a decrease in nocturnal
erections. His past medical history is significant for diabetes mellitus. type 2 and benign prostatic hypertrophy
(BPH). His current medications are glyburide and doxazosin. Physical examination is insignificant. HbA1c
level measured two weeks ago was 7.5%. He is asking about a prescription for sildenafil. Which of the
following is the best statement concerning the treatment of erectile dysfunction in this patient?

r A. Tightening of glycemic control improves erectile dysfunction

r B. Sildenafil is not a drug of choice for diabetics with erectile dysfunction
r C. Sildenafil and doxazosin should be given with at least a 4-hour interval
r D. Prostaglandins (alprostadil) are preferred in this patient
r E. Sildenafil should not be combined with glyburide

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Item: 44 of 44

!II PMark

Q.ld: 3729 [

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A 30-year-old Caucasian female comes to the physician's office because of polyuria and polydipsia of recent
onset. She has no other medical problems. She does not use tobacco. alcohol or drugs. She has no known
drug allergies. Her mother has diabetes. Her temperature is 36.7C (98F). pulse is 75/min. blood pressure is
11 0/70 mm Hg. and respirations are 15/min. The initial lab results are:
Hb
WBC
Platelets
Blood glucose
Serum sodium
Serum potassium
Bicarbonate
BUN
Serum creatinine
Serum uric acid
Serum osmolality
Urine osmolality

12.7 g/dl
5.000 /cmm
380 .000/cmm
90 mg/dl
142 mEq/L
4.0 mEq/L
26 mEq/L
15 mg/dl
0.9 mg/dl
9 mg/dl
295 mOsm/kg
160 mOsm/kg

After 12 hours of water deprivation. lab testing reveals:

Serum sodium
Serum potassium
Bicarbonate
Serum osmolality
Urine osmolality

151 mEq/L
4.2 mEq/L
26 mEq/L
300 mOsm/kg
186 mOsm/kg

One hour after the subcutaneous administration of arginine vasopressin. the urine osmolality is 400
mosm/kg. Which of the following is the most appropriate treatment for this patient?

r
r
r
r
r

A. Psychotherapy
B. Intranasal desmopressin acetate
C. Indomethacin
D. Hydrochlorothiazide
E. Demeclocycline

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