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 # 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 # 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 # 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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