Q 1 . A 68-year-old woman with stage IIIB squamous cell
carcinoma of the lung is admitted to the hospital because
of altered mental status and dehydration. Upon admission,
she is found to have a calcium level of 19.6 mg/dL
and phosphate of 1.8 mg/dL. Concomitant measurement
of parathyroid hormone was 0.1 pg/mL (normal 10–65
pg/mL), and a screen for parathyroid hormone–related
peptide was positive. Over the first 24 h, the patient receives
4 L of normal saline with furosemide diuresis. The
next morning, the patient’s calcium is now 17.6 mg/dL
and phosphate is 2.2 mg/dL. She continues to have delirium.
What is the best approach for ongoing treatment of
this patient’s hypercalcemia?
A. Continue therapy with large-volume fluid administration
and forced diuresis with furosemide.
B. Continue therapy with large-volume fluid administration,
but stop furosemide and treat with hydrochlorothiazide.
C. Initiate therapy with calcitonin alone.
D. Initiate therapy with pamidronate alone.
E. Initiate therapy with calcitonin and pamidronate.
Answer E
Q 2 . A 54-year-old woman is referred to endocrinology
for evaluation of osteoporosis after a recent evaluation of
back pain revealed a compression fracture of the T4 vertebral
body. She is perimenopausal with irregular menstrual
periods and frequent hot flashes. She does not
smoke. She otherwise is well and healthy. Her weight is 70
kg, and height is 168 cm. A bone mineral density scan
shows a T-score of –3.5 SD and a Z-score of –2.5 SD. All
of the following tests are indicated for the evaluation of
osteoporosis in this patient except
A. 24-h urine calcium
B. follicle-stimulating hormone and luteinizing hormone
levels
C. serum calcium
D. renal function panel
E. vitamin D levels (25-hydroxyvitamin D)
Answer B
Q 3 A 67-year-old woman presents to clinic after a fall
on the ice a week ago. She visited the local emergency
room immediately after the fall, where hip radiographs
were performed and were negative for fracture or dislocation.
They did reveal fusion of the sacroiliac joints and
coarse trabeculations in the ilium, consistent with Paget
disease. A comprehensive metabolic panel was also sent
at that visit and is remarkable for an alkaline phosphatase
of 157 U/L, with normal serum calcium and phosphate
levels. She was discharged with analgesics and told
to follow up with her primary care doctor for further
management of her radiographic findings. She is recovering
from her fall and denies any long-standing pain or
immobility of her hip joints. She states that her father
suffered from a bone disease that caused him headaches
and hearing loss near the end of his life. She is very concerned
about the radiographs and wants to know what
they mean. Which of the following is the best treatment
strategy at this point?
A. Initiate physical therapy and non-weight bearing exercises
to strengthen the hip.
B. No treatment; she is asymptomatic. Follow radiographs
and laboratory findings every 6 months.
C. Prescribe vitamin D and calcium.
D. Start an oral bisphosphonate.
E. Start high-dose prednisone with rapid taper over 1
week.
Answer D
Q 4 . A 26-year-old woman presents with 2 weeks of nausea,
vomiting, and jaundice. She has been previously
healthy and has no past medical history. On examination,
a palpable liver edge is appreciated. Ocular findings are
presented in Figure X-14 (Color Atlas). Her transaminases
and total bilirubin are elevated. Which of the following
tests will lead to a definitive diagnosis in this patient?
A. Anti-smooth-muscle antibody
B. Hepatitis B surface antigen
C. Liver biopsy with quantitative copper assay
D. Serum ceruloplasmin
E. Total iron-binding capacity and ferritin
Answer C
Q 5 . A 29-year-old woman presents to your clinic complaining
of difficulty swallowing, sore throat, and tender
swelling in her neck. She has also noted fevers intermittently
over the past week. Several weeks prior to her current
symptoms she experienced symptoms of an upper
respiratory tract infection. She has no past medical history.
On physical examination, she is noted to have a
small goiter that is painful to the touch. Her oropharynx
is clear. Laboratory studies are sent, and reveal a white
blood cell count of 14,100 cells/ μL with a normal differential,
erythrocyte sedimentation rate (ESR) of 53 mm/h,
and a thyroid-stimulating hormone (TSH) of 21 μΙU/mL.
Thyroid antibodies are negative. What is the most likely
diagnosis?
A. Autoimmune hypothyroidism
B. Cat-scratch fever
C. Graves’ disease
D. Ludwig’s angina
E. Subacute thyroiditis
Answer E
Q 6 . What is the most appropriate treatment for the patient
described above?
A. Iodine ablation of the thyroid
B. Large doses of aspirin
C. Local radiation therapy
D. No treatment necessary
E. Propylthiouracil
Answer B
Q 7 . The Diabetes Control and Complications Trial (DCCT)
provided definitive proof that reduction in chronic hyperglycemia
A. improves microvascular complications in type 1 diabetes
mellitus
B. improves macrovascular complications in type 1 diabetes
mellitus
C. improves microvascular complications in type 2 diabetes
mellitus
D. improves macrovascular complications in type 2 diabetes
mellitus
E. improves both microvascular and macrovascular
complications in type 2 diabetes mellitus
Answer A
Q 8 . A 54-year-old woman undergoes thyroidectomy for
follicular carcinoma of the thyroid. About 6 h after surgery,
the patient complains of tingling around her mouth.
She subsequently develops a pins-and-needles sensation
in the fingers and toes. The nurse calls the physician to
the bedside to evaluate the patient after she has severe
hand cramps when her blood pressure is taken. Upon
evaluation, the patient is still complaining of intermittent
cramping of her hands. Since surgery, she has received
morphine sulfate, 2 mg, for pain and compazine, 5 mg,
for nausea. She has had no change in her vital signs and is
afebrile. Tapping on the inferior portion of the zygomatic
arch 2 cm anterior to the ear produces twitching at the
corner of the mouth. An electrocardiogram (ECG) shows
a QT interval of 575 ms. What is the next step in evaluation
and treatment of this patient?
A. Administration of benztropine, 2 mg IV
B. Administration of calcium gluconate, 2 g IV
C. Administration of magnesium sulphate, 4 g IV
D. Measurement of calcium, magnesium, phosphate,
and potassium levels
E. Measurement of forced vital capacity
Answer B
Q 9 . A 49-year-old male is brought to the hospital by his
family because of confusion and dehydration. The family
reports that for the last 3 weeks he has had persistent
copious watery diarrhea that has not abated with the use
of over-the-counter medications. The diarrhea has been
unrelated to food intake and has persisted during fasting.
The stool does not appear fatty and is not malodorous.
The patient works as an attorney, is a vegetarian,
and has not traveled recently. No one in the household
has had similar symptoms. Before the onset of diarrhea,
he had mild anorexia and a 5-lb weight loss. Since the
diarrhea began, he has lost at least 10 pounds. The physical
examination is notable for blood pressure of 100/70,
heart rate of 110/min, and temperature of 36.8°C
(98.2°F). Other than poor skin turgor, confusion, and
diffuse muscle weakness, the physical examination is
unremarkable. Laboratory studies are notable for a normal
complete blood count and the following chemistry
results:
Na+ 146 meq/L
K+ 3.0 meq/L
Cl– 96 meq/L
HCO3
– 36 meq/L
BUN 32 mg/dL
Creatinine 1.2 mg/dL
A 24-h stool collection yields 3 L of tea-colored stool.
Stool sodium is 50 meq/L, potassium is 25 meq/L, and
stool osmolality is 170 mosmol/L. Which of the following
diagnostic tests is most likely to yield the correct diagnosis?
A. Serum cortisol
B Serum TSH
C. Serum VIP
D. Urinary 5-HIAA
E. Urinary metanephrine
Answer C
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