ENDOCRINOLOGY AND METABOLISM MULTIPLE CHOICE QUESTIONS

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