USMLE STep 3 Question #486

A 56-year-old male with Type II diabetes presents to you today for a follow-up visit. Three months prior his A1c was 8.9% and he was started on metformin. Today his A1c is 7.4%. He is significantly overweight with a BMI of 33. You would like to initiate another medication for glucose control, specifically one that does not carry a risk of weight gain. Which of the following drugs is weight neutral?

  • A.  Glimepride
  • B. Rosiglitazone
  • C.  Pioglitazone
  • D. Sitagliptin
  • E. Glyburide

Question of the Week # 448 and 449

Q448  ) A 78 year old man presents to emergency room with severe pain in his right lower extremity. Pain began after he stumbled and fell on a sidewalk. He does not report pain anywhere else and did not lose consciousness. No tingling or numbness in either extremity. He reports inability to bear weight because it is extremely painful. His past medical history is significant for coronary artery disease and hypertension. He does report about 8lbs weight-loss in the past 1 month.  On examination, he is afebrile. There is tenderness in the right thigh area. Laboratory investigations reveal Hemoglobin 10.5gm%, Platelet count 110k/ul, Calcium at 10.4 mg/dl ( N = 9.0 to 10.5 mg/dl) , Serum creatinine 2.0 mg/dl, Total protein 4.5 gm/dl, Albumin 2.0gm/dl and Ferritin 200 ng/ml.  Liver function tests including Alkaline phosphatase are within normal limits. Whole body bone scan is negative for any lesions. Serum protein electrophoresis is normal with out any monoclonal spike.

An x-ray of the femur is shown  below :

bone

448) Which of the following is most helpful in diagnosing this condition?

A) Colonoscopy

B) DEXA scan

C) 24 hour urine electrophoresis

D) Vitamin D level

E) Parathyroid hormone level

 

449) Which of the following is likely to explain the patient’s findings?

A) Metastatic colon cancer

B) Multiple Myeloma

C) Osteoporosis

D) Secondary Hyperparathyroidism

E) Metastatic Prostate cancer

Question of the Week # 421

421) A 34-year-old woman with history of oligomenorrhea presents to your clinic to discuss her results of recent work-up. One week ago, she has undergone extensive work-up for her menstrual abnormality. A serum pregnancy test is negative. Thyroid stimulating hormone, serum prolactin  level and Follicle Stimulating Hormone levels are within normal limits. Serum total testosterone is 120ng/dl ( N = 30 to 90ng/dl) and serum free testosterone is 0.9 ng/dl ( N= 0.4 to 0.8 ng/dl) . A dehydro-epiandrosterone level is 400 mcg/dl (45- 270 ug/dL) . A pelvic ultrasound reveals multiple cysts in the ovaries bilaterally. On examination, she is obese with a BMI of 32. She has excess thick and pigmented hair above her upper lip and on the chin. Which of the following is indicated in this patient at this time?

A) Fasting Plasma Glucose

B) Random Blood Glucose

C) Hemoglobin A1C

D) Oral Glucose Tolerance Test

E) Start Metformin

Question of the Week # 420

420) A 34-year-old woman with past medical history of Hypothyroidism presents to the outpatient clinic for follow-up visit. She delivered a health male baby about one week ago and has been breast feeding without any issues. She has no complaints. During the pregnancy she required increase of her levothyroxine dose to 0.175 mcg from  her usual pre-pregnancy dose of 0.125mcg. Her TSH level about 2 weeks ago was 2.0µu/ml. She denies any cold or heat intolerance, weakness or constipation. On physical examination, vitals are stable. There is no goiter. Deep tendon reflexes are normal.  Which of the following is the most appropriate management at this time?

A) Decrease Levothyroxine to pre-pregnancy dose and recheck TSH in 6 weeks

B) Repeat TSH in 6 weeks before dose adjustment

C) Increase Levothyroxine and repeat TSH in 6 weeks

D) Repeat TSH now

E) Obatin Thyroid Peroxidase antibodies

Question of the Week # 419

419) A 26-year-old woman presents for an ante-natal check up after her home pregnancy test showed positive result. Her last menstrual period was 5 weeks ago. Her past medical history includes hypothyroidism for which she has been using 125 mcg of levo-thyroxine for the past five years. She did not require any dose adjustment of her thyroid hormone therapy in the past 4 years. Her most recent thyroid stimulating hormone level ( TSH) was performed 2 weeks ago and was 2.5µU/ml ( N = 0.5 to 5.0 µU/ml). She denies any cold intolerance, weakness or constipation. She has gained about 2 lbs weight in the past one month. On physical examination, vitals are stable. There is no goiter. Reflexes are 1+ in bilateral lower extremities and there is 1+ pre-tibial edema. Laboratory investigations reveal :

Thyroid Stimulating Hormone :  2.5 µU/ml( N = 0.5 to 5.0 µU/ml)

Serum Total T4: 13.9 µg/dl ( N = 5 to 12µg/dl)

Serum Free T4 :  1.9 ng/dl ( N = 0.9 to 2.4ng/dl)

Which of the following is the most recommendation?

A) Decrease Levothyroxine and recheck TSH in 4 weeks

B) Continue same dose Levothyroxine and repeat TSH in 4 weeks

C) Increase Levothyroxine and repeat TSH in 4 weeks

D) Repeat TSH in 8 to 10 weeks

E) Check Serum thyroid binding globulin levels

Question of the Week # 390

390)  A 28 year old woman has had amenorrhea for the past 4 months. She reports having regular menstrual cycles prior to these episodes. She is sexually active and a home pregnancy test was negative on two occasions over the last one week. She denies any excessive stress or physical activity. She has had headaches almost daily over the past three months. She denies any visual deficits. Her past medical history is significant for schizophrenia for which she is using risperdal for several years with good control of her disease. On examination, her vitals are stable. Body mass index is about 28 . There is milky discharge on breast examination. Pelvic exam is normal. Serum pregnancy test is negative. A serum prolactin level is 30mcg/ml (5 to 20 mcg/L). A serum Thyroid Stimulating Hormone and Follicle Stimulating Hormone level are within normal limit. An MRI of the brain reveals 10 cm lobulated mass in the anterior skull base. Which of the following is the initial step in evaluating this patient?

A) Repeat Prolactin after Serum Dilution

B) Discontinue Risperdal

C) Trans-Sphenoidal Resection of the Tumor

D) Pituitary Irradiation

E) Bromocriptine

Question of the Week # 389

389)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

Question of the week # 300

300) A 14 year old girl is evaluated in your office for  moderate headache of one month duration . She denies any blurred vision, neck stiffness or fever. She is accompanied by her mother who reports that her performance at school has progressively declined over the last few months and she has deepening of voice for the past 4 months. On examination, Pulse 80/min;  Temperature: 98.4F  and Blood pressure: 135/100 mm of Hg. There is excessive hair on her face. Rest of the physical is normal except for faint purplish marks on her abdomen. Laboratory investigations including complete blood count, comprehensive metabolic panel and Urine analysis are within normal limit. Which of the following is the most appropriate next step ?

A) 24 hour urinary cortisol

B) MRI brain

C) CT scan of the abdomen

D) Dexamethasone Suppression Test

E) Plasma catecholamines

F) Urine Drug Screen

Question of the week # 291

291) A 66 year old man with past medical history of hypertension and  type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection.  On the times that he does have an erection, they are very soft.  He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship.  He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been “perfect”. A Hemoglobin A1C 2 weeks ago was 6.0gm% .  He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

 

Question of the week # 290

290) A 72 year old man with history of Diabetes Mellitus and peripheral vascular disease is evaluated in your office for impotence. He denies any premature ejaculation and states that he can not even attain an erection. Further studies confirm erectlie dysfunction secondary to organic causes. The patient denies any history of angina in the past. His medications include Aspirin, Clopidogrel, Glargine insulin and Lispro. His most recent HGBA1C was 6.5%. You offer him sildenafil for erectlie dysfunction. He is now concerned about the possible side effects. Which of the following is the most common side effect of sildenafil?

A) Headache

B) Nasal congestion

C) Diarrhea

D) Blurred vision

E) Flu like symptoms

Question of the week # 289

289) A 32 year old male athlete is evaluated in the office for bilateral breast enlargement. He is a state champion in running and is scheduled to participate in the national level running championship in few weeks. He is very concerned about his appearance.   He denies using any illicit drugs or exogenous androgens or aromatase inhibitors  is seen in the office during a routine follow up visit.  His past medical history is unremarkable. Physical examination reveals gynecomastia bilaterally. His laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 18.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most useful in establishing the diagnosis?

A) Erythropoetin level

B) Urine Drug Screen

C) Serum Total Testosterone

D) Urine Testosterone/ Epitestosterone ratio

E) Serum Free Testosterone

Question of the week # 288

288) A 38 year old caucasian man  is seen in the office during a routine follow up visit.  His past medical history is significant for testicular non-seminomatous germ cell tumor diagnosed 9 months ago and was treated with radical orchiectomy of left testicle and chemotherapy.  He completed chemotherapy 6 months ago and achieved a complete response. His tumor markers and imaging studies 3 months after completion of therapy were normal. He complains of decreased sexual drive and energy.  He denies smoking tobacco or alcohol. He  uses Marijuana on a daily basis but quit 2 months ago. His family history is unremarkable.  Physical examination shows absent left testicle. Rest of the physical is normal. Serum alpha-fetoprotein is normal. Beta HCG is elevated at 15U/L ( Normal < 5 U/L) . A chest X-ray , CT scan of the abdomen and pelvis are normal.  His routine laboratory investigations including complete blood count are within normal limits. Which of the following is most likely reason for his elevated Beta-HCG?

A) Recurrent tumor

B) Marijuana Use

C) Hypogonadism

D) Chemotherapy effect

E) Hyperthyroidism

Question of the week # 287

287) A 38 year old caucasian man  is seen in the office due to decreased libido and energy. His past medical history is significant for testicular cancer diagnosed 1 year ago and was treated with radical orchiectomy of left testicle and chemotherapy. He denies smoking tobacco but admits using Marijuana on a daily basis for the past few months. His family history is unremarkable.  Physical examination  reveals gynecomastia and absent left testicle. Body mass index is 24.  His routine laboratory investigations including complete blood count are within normal limits. Serum total testosterone level is reduced and Serum LH concentration is elevated. The patient is started on Testosterone replacement therapy with a testosterone skin gel. Which of the following is the most appropriate step in follow up care of  this patient after starting testosterone therapy?

A) Digital Rectal exam and Serum PSA level at one year

B) Hematocrit at 6 months and then, every year

C) DEXA scan at one year

D) Serum Testosterone level at 6 months

E) Serum LH at one month.

Question of the Week # 265

265 )  A 52 year old woman presents to your office with complaints of increased thirst and increased urinary frequency. Her other medical problems include Hypertension and Dyslipidemia. Blood pressure has been under control on enalapril. Her family history is significant for diabetes mellitus and Hypertension.  Physical examination reveals an obese woman in no apparent distress. Blood pressure is at 135/80 mm Hg. Velvety thickened skin is noted in bilateral axillae. Which of the following results will establish the diagnosis that could explain the symptoms and physical examination findings in this patient?

A) Random plasma glucose > 180mg%

B) Hemoglobin A1c > 6.5%

C) Fasting Blood Sugar > 110 mg%

D)  Oral Glucose Tolerance Test  , plasma glucose ≥120 mg% at 2 hours

E)  Urine glucose > 300 mg%

Question of the Week # 264

264 )  A 52 year old woman presents to your office with complaints of increased thirst and increased urinary frequency. Her family history is significant for diabetes mellitus and Hypertension. A glucometer reading obtained in the office shows 260mg%. Hemoglobin A1C is 7.0% . The patient is subsequently started on Metformin. Three days after starting Metformin, she presents with nausea and diarrhea. She denies any fever or abdominal pain. Physical examination is within normal limits. Random glucometer reading shows 130mg%. Comprehensive metabolic panel is within normal limits. Which of the following is the most appropriate next step in managing this patient’s symptoms?

A) Discontinue Metformin

B) Check lactic acid level

C) Recommend Metformin to be taken with meals.

D)  Check serum ketones

E) Insulin drip

Question of the Week # 261

261 )  A 30 year old woman presents to your office for a routine physical examination. She feels well and denies any symptoms. Her past medical history is significant for mediastinal Hodgkin’s lymphoma diagnosed at the age of 18 years. She was treated with chemotherapy and involved field radiation therapy at that time. She has a history of hypothyroidism that was diagnosed 8 years ago and has been on levothyroxine therapy. A Thyroid Stimulating Hormone level 2 months ago was within normal limits. Physical examination reveals normal vitals. There is no palpable goiter.  Rest of the physical exam is unremarkable. Routine labortatory investigations and chest x-ray are normal.  Which of the following is the most appropriate recommendation for this patient at this time?

A)   PET/ CT scan

B)    CT scan of Chest, Abdomen and Pelvis

C)     Mammogram

D)     Cardiac catheterization

E)    Anti-microsomal antibodies

Question of the Week # 254

254 )  A 72 year old man with history of metastatic prostate cancer is admitted with severe weakness and lethargy. He has been having vomiting and abdominal pain for the past two weeks.  He also reports intermittent diarrhea alternating with constipation over the past 2 months. Three months ago, he was noted to have progressive prostate cancer despite therapy with bicalutamide and leuprolide. His PSA at that time was 300ng/ml. He was started on Ketoconozole at that time and he is compliant with it. His most recent visit to the outpatient clinic was 4 weeks ago at which time his PSA was 60ng/ml. On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 70/40 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A CT scan of the adbomen reveals enlarged prostate and osteoblastic bone metastases in pelvis but no evidence of bowel obstruction. Urinalysis and Chest x-ray are benign. The patient is started on intravenous isotonic saline. Which of the following is the most appropriate next step in managing this patient?

A) Start Chemotherapy

B) Refer to Hospice

C) Intravenous Hydrocortisone

D) Start Norepinephrine drip

E) Intravenous Biphosphonates

 

Question of the Week # 251

251 )  A 65 year old woman is evaluated in your office for pain in bilateral feet for the past four weeks. The pain is burning in quality and is associated with intense itching. Her past medical history is significant for difficult to control Type II Diabetes Mellitus. Her recent HgbA1C was 7.9% and Creatinine was 1.8mg%.  On physical examination, she is obese, afebrile and in no apparent distress. She has diminished pinprick and vibration sensation in glove and stocking pattern in bilateral upper and lower extremities. Dorsalis pedis and posterior tibial pulses are mildly diminished. There are multiple erythematous tiny vesicles between the toes and on the plantar aspect of the both feet.  Which of the following is the most appropriate treatment option for this patient’s pain?

A)      Oral Pregabilin

B)      Topical Corticosteroids

C)      Oral Cefazolin

D)     Topical Terbinafine

E)     Topical Acyclovir

Question of the Week # 196

196)  A 72 year old obese woman is evaluated during a follow up visit for Diabetes Mellitus Type II. She had been started on Insulin therapy 5 years ago after several months of oral hypoglycemic drug therapy that failed to improve her glycemic control. Her insulin regimen includes 40 units of Insulin Glargine at bed time and 10 units of Regular insulin 30 minutes before each meal.  She has been maintained on this regimen for the past 2 years. She had two recent hypoglycemic episodes for which she was treated in the Emergency Room. She now reports that she had been taking only 5 units of Regular insulin before meals but her post-prandial glucometer reading has usually, been on the lower side of the normal range. At this rate of decreased insulin use, she believes she will be cured of diabetes by the end of the year. She denies any recent weight changes. She denies any depression or drug overdose. Physical examination is consistent with diabetic neuropathy in bilateral lower extremities.  The most appropriate next step in managing this patient:

A)     Urine Sulfonyl Urea screen

B)      C-peptide level

C)      Renal Function Tests

D)     Stop Insulin therapy

E)      Switch to Regular insulin to Lispro

Question of the Week # 178

Q177) A 55-year-old white woman is seen in your office for a 6-month  history of slowly enlarging lesions on both lower extremities. She is otherwise healthy. The lesions are painless. She denies any trauma to these areas. Her past medical history is significant for diabetes mellitus diagnosed 2 years ago and rheumatoid arthritis. Her medications include Metformin, Enalapril and Methotrexate. On skin examination, she has  2 cm yellow, smooth, firm centrally depressed plaques involving the thighs and knees. Image is shown below

 

 

 

 

 

 

 

 

The most likely underlying etiology :

A) Drug-induced

B) Rheumatoid arthritis

C) Diabetes Mellitus

D) Malignancy

E) Sarcoidosis

Question of the Week # 177

Q177) A 52 Year old obese man is evaluated in your office during a routine annual visit.  He denies any fatigue or recent weight changes. He has normal appetite and physically active. He had a colonoscopy 1 year ago that was normal. On physical examination, he is obese with a BMI of  34. Skin examination reveals the findings shown in the image below :

 

 

 

 

 

 

 

 

 

Which of the following is most likely to be seen in this patient?

A) Diabetes Mellitus, Type I

B) Gastric cancer

C) Increased Insulin levels

D) Hyperthyroidism

E) Addison’s disease

Question of the Week # 159, 160

159) A 65 year old man with history of Diabetes Mellitus Type II and Hypertension is evaluated for a one month history of numbness in bilateral hands and feet. He has been feeling excessively tired lately. His medications include Glyburide, Metformin and Enalapril for the past 5 years. Physical examination reveals loss of position sensation in bilateral lower extremities.  He reports good control of blood pressure and Diabetes. His recent HgBA1C was 6.0% 1 month ago. His laboratory tests reveal a Hemoglobin of 9.0gm%; WBC of 8.0k/µl, MCV of 103 and Platelets of 200k/µl. Once the diagnosis is confirmed, the most important therapeutic step in addressing this patient’s presentation:

A) Stop Metformin

B) Switch to insulin

C) Vitamin b12 and Calcium supplementation

D) Start Gabapentin

E) Start Thyroid Supplements

160) In Question above, the most likely underlying cause of this patient’s presentation:

A) Diabetes related complications

B) Chronic Metformin Use

C) Poor Glycemic Control

D) Myelodysplastic Syndrome

E) Hypothyroidism 

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