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 # 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 # 83, 84, 85

Q83) 35-year-old man with a 10-year history of type 1 diabetes mellitus is evaluated because of recent onset of morning hyperglycemia. His home blood sugar logs over the last 10 days have consistently been showing elevated sugars in the range of 220 to 300 mg% in the early morning ( pre-breakfast).  He has also experienced nightmares recently. He has been compliant with his diet instructions and has  not changed his dinner potions recently.  He takes mixed insulin regimen :  NPH/Regular  insulin 70/30 mix at  30 units in the AM before breakfast and 20 units in PM 30 minutes before dinner. Which of the following best explains this patient’s morning hyperglycemia?

( A ) Diabetic nephropathy

( B ) Undertreatment with insulin

( C ) Overtreatment with insulin

( D ) Insulinoma

(E) Non compliance with Insulin

Q84) The best diagnostic study in establishing the diagnosis in this patient :

A) C-Peptide level

B) Urine 24 hour catecholamines

C) Check pre-dinner blood sugar level

D) Check blood sugar level 30 minutes post – dinner

E) Check blood sugar level between 2:00 AM and 3:00 AM

Q85) Next best step in managing this patient’s pre-breakfast hyperglycemia :

A) Increase pre-breakfast regular insulin dosage in AM

B) Increase pre-dinner regular insulin dose

C) Reduce pre-dinner NPH insulin dose

D) Decrease the carbohydrate consumption in the night

E) Discontinue Pre-dinner insulin

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