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E1. Which drug does not cause hypoglycaemia in the elderly?
* Acarbose is a competitive inhibitor of pancreatic α-amylase and intestinal brush border α-glucosidases, resulting in delayed hydrolysis of ingested complex carbohydrates and disaccharides and absorption of glucose.
* Does not cause hypoglycemia
E2. In primary hyperaldosteronism, which of the following is seen?
A. Metabolic alkalosis, low renin
B. Metabolic acidosis, low renin
C. Metabolic alkalosis, high renin
D. Metabolic acidosis, high rennin
E3. Diabetic man with recent onset of diarrhoea and fecal incontinence. He also has a 1 year history of constipation. The most likely cause of his symptoms is:
A. Inflammatory bowel disease
B. Colon cancer
C. CoccidiomycosisD. Autonomic neuropathy
* Colon Ca a possibility, but 1 year Hx with no other constitutional SSx makes it less likely
* likely constipation secondary to autonomic dysfxn, now presenting with overflow diarrhea
E4. Woman with Cushing’s syndrome. Cortisol does not suppress with low dose dexamethasone test but does suppress with high dose test. Diagnosis:
A. Adrenal adenoma
B. Adrenal carcinoma
C. Ectopic ACTH
D. Pituitary adenoma
* Failure of cortisol suppression with low-dose dexamethasone suppression test confirms Cushing’s syndrome.
* Suppression of cortisol suppression with high dose dexamethasone suppression will occur with ACTH from a pituitary adenoma, but not ectopic ACTH production.
5. Woman with known Hx of DM I and hypothyroidism presents with weakness, dizziness, weight loss and orthostatic drop in BP. Normal TSH and HbA1C is 0.07. Next step:
B. Dexamethasone suppression test
C. Tighter glucose control
D. ACTH stimulation test
E6. 20F with a 2 year hx of hirsutism and oligomenorrhoea. DHEA and 17-OH progesterone both elevated. Normal testosterone, LH, FSH and overnight dexamethasone suppression test. Normal pelvic exam. Treatment:
A. Oral contraceptive pill
B. Prednisone 2.5-5.0 mg OD
D. Wedge resection of the ovaries
E. Bilateral adrenalectomy
E7. 18 year old male with gynaecomastia, chest pain, fatigue, and loss of retrosternal airspace on CXR. Diagnosis:
B. Germ cell tumour
D. Hodgkin’s disease
E8. 25M with hypokalemia, bicarbonate of 28 and urine chloride of 40. Diagnosis:
C. Primary hyperaldosteronism
D. Post hypercapnoea
A - vomiting: Low urine Cl
B - diarrhea: causes acidosis, loss of HCO3
C CORRECT - primary hyperaldosteronism: Consistent, would expect Alkalosis and high Urine Cl
D - post-hypercapnea: Low urine Cl
E - low chloride diet: Low urine Cl
E9. Cushingoid female who’s serum cortisol does not suppress with low dose dexamethasone. Low serum ACTH. Next step:
A. 24h cortisol and 17-hydroxysteroids after high dose suppression test
B. 24h cortisol and 17-hydroxysteroids after low dose suppression test
C. CT abdomen
D. MRI pituitary
E10. 18M with DKA. Initial pH 6.96, glucose 28. Given 2L NS over 2 hours, 10 units of IV insulin bolus then 3 units per hour. Now pH is 7.01 and glucose is 23. Next step:
A. Double the insulin rate
B. 1 Litre D5W over 30 minutes
C. Give bicarbonate
D. Continue with current treatment
E11. 60M with DM2 on human NPH 50 units q AM. Nocturia, morning BS 10, elevated HbA1c. Next step:
A. Add 10 units NPH at night
B. Use intense insulin regimen
C. Add glyburide
D. Switch to non-human insulin
* Nocturia suggests nocturnal hyperglycemia. Morning fasting blood glucose is above target. Therefore, add evening NPH.
E12. Which is true regarding the treatment of Graves’ disease?
A. Radioactive iodine has a low but significant risk for malignancy
B. Long-term use of antithyroid medications can result in remission
C. If radioactive iodine fails may go on to subtotal thyroidectomy in 6 months
D. Opthalmopathy is an indication for urgent thyroidectomy.
A - small rise in thyroid cancer with iodine, may be related to pre-existing disease
B CORRECT - ATD: after 1-2 years of treatment, can have remission
C - if radioiodine fails, may need multiple treatments. doesn't mean auto-referral for sx
D - false
E13. 28F 19 weeks pregnant. Diagnosed with Graves’ disease. Treatment:
A. No treatment
C. PTU 100 mg bid
E. Radioactive iodine
E13B. Most effective therapy for severe thyrotoxicosis seen in Graves:
A. Immediate I131
C. Lugol’s cold solution and propranolol
D. Lugol’s and B blocker and steroid and PTU
E14. In the setting of primary hyperparathyroidism you would expect:
A. Decreased PTH, low urinary calcium
B. Decreased PTH, high urinary calcium
C. Decreased PTH, normal urinary calcium
D. Increased PTH, low urinary calcium
E. Increased PTH, high urinary calcium
E15. Elderly patient diagnosed with Paget’s disease. Most appropriate management option:
A. Bone biopsy
B. Analgaesics and bisphosphonates
C. Work up for osteosarcoma
E16. 26 year old diabetic with BP 130/80, microalbuminuria. No overt proteinuria. Treatment:
A. Start ACEi
B. Start ACEi if overt diabetic nephropathy
C. Repeat 24 hour urine for protein in 6 months
D. Repeat 24 hour urine for protein in 1 year
E17. Elderly male with longstanding diabetes which is poorly controlled presents with right buttock and thigh pain and has quadriceps and thigh muscle wasting. He also complains of fatigue and weight loss. He has:
A. Parathyroid syndrome
D. Diabetic neuropathy
* Acute, asymmetric, focal onset of pain followed by weakness involving the proximal leg, with associated autonomic failure and weight loss.
* Progression occurs over months and is followed by partial recovery in most patients.
E18. Young woman with ulcerative colitis, not responding to 5-ASA. You want to start corticosteroids. The following is true about steroid use:
A. Bisphosphonates decrease the risk of vertebral fractures
B. They inevitably lead to osteoporosis in the long term
C. 2/3 of patients will have a fracture in 5-10 years
D. Vitamin D and calcium are effective therapy
E19. The following is true with respect to osteomalacia:
A. Pain is characteristic
B. It is usually due to dietary calcium deficiency
C. Usually presents with decreased calcium and increased ALP and PO4
D. Rarely has increased PTH
E20. Old woman with lumbar fracture and past history of breast cancer. On vitamin D and Calcium. What treatment would you start now?
A. Estrogen replacement
D. 1,25 dihydroxy vitamin D
E21. Back pain, x-rays showing osteopaenic spine, scapula with linear radioluscencies (looser zones). Ca 2.10, Pi 0.75, ALP 125. This is most in keeping with:
A. Primary biliary cirrhosis
B. Chronic pancreatic insufficiency
C. Celiac disease
D. Intestinal bypass
E22. DM2. Best indication to use insulin:
A. Thin patient, young and newly diagnosed
C. Weight loss, polyuria and lethargy on an oral agent
CDA Guidelines recommend starting insulin (+metformin) upfront in DM2 with symptomatic hyperglycemia and metabolic decompensation.
E23. A patient with diabetes has hypertension ~180/90. No proteinuria. What should be the target blood pressure?
E24. 58F falls and suffers a vertebral compression fracture. BMD confirms osteoporosis. Prior TAH/BSO at age 40. Prior DVT. Pain controlled with Tylenol. Best treatment:
C. SERM (Raloxifene)
A - Estrogen associated with increased CV risk (MI/stroke), breast cancer and DVT
B - same as above
C - SERM such as Raloxifene is a first line agent to reduce risk of vertebral fractures in post-menopausal women, but contraindicated here due to hx of DVT
D CORRECT - Bisphosphenate
E25. A man is found to have a squamous cell carcinoma of lung. Normal bone scan. Hypercalcemic, hyperphosphatemic, elevated PTH, Cr 210. What is the cause of the hypercalcemia:
A. Parathyroid related peptide
B. Bony metastases
D. Renal failure
E26. What treatment has been shown to decrease the rate of progression of proliferative diabetic retinopathy?
A. Panretinal laser photocoagulation
B. Subcutaneous heparin
C. ACE inhibitor
D. Tight glycemic control
C - ADVANCE and ACCORD studies showed no benefit of BP control on retinopathy
D - Evidence for tight glycemic control to be beneficial in primary prevention and early retinopathy
E27. 60M DM2 (well-controlled on OHG), CAD (MI 6/120), with erectile dysfunction. HbA1c 6.8. on metoprolol, ACE, statin, and ASA. Stress test: mild ischemia on maximal exertion. His testosterone and prolactin levels are normal. What is the best therapy for his erectile dysfunction?
A. Stop the statin
B. Stop the beta-blocker
C. Give testosterone injections
D. Prescribe sildenafil
DDx for erectile dysfunction:
* Psychologic: anxiety, depression
* Neurologic: central
* Vascular: cardiovascular disease, hypertension, smoking, dyslipidemia
* Endocrine: diabetes, thyroid, hypogonadism, hyperprolactinemia
* Drugs: SSRI, beta blockers, thiazides, substance abuse
* Genitourinary trauma: urologic surgery or trauma
E28. A woman has had multiple kidney stones. Investigations reveal serum calcium 3.1, low serum phosphate, high urinary calcium, and PTH at upper limit of normal. Best next step:
A. Referal to a surgeon for parathyroidectomy
B. Parathyroid scan
C. Skeletal survey
D. Bone scan
A CORRECT: Diagnosis consistent with primary hyperparathyroidism
B - Parathyroid imaging used for localization of adenoma before surgery but not used for diagnosis. Imaging options include ultrasound, sestimabi scan and CT. The optimal pre-op imaging modality is best discussed with the surgeon.
C - skeletal survey not needed for diagnosis
D - bone scan: not needed for diagnosis
E29. Obese 17F presents with worsening hirsutism. (Other details?) Most likely cause?
A. Polycystic ovarian syndrome
B. Late-onset congenital adrenal hyperplasia
C. Ovarian tumour
E30. A young female presents with severe loss of bone density and multiple pathologic fractures. She is found to have glucosuria, metabolic acidosis, HCO3 10, K 2.8, Ca ?, PO4 ?. Most likely diagnosis?
A. Distal renal tubular acidosis and osteomalacia
C. Fanconi syndrome
* Generalized proximal tubular dysfunction (often appears like a proximal or Type II RTA)
* bicarbonaturia, glucosuria, phosphaturia, uricosuria, aminoaciduria, proteinuria → hypophosphatemia, hypouricosemia.
* H+/K+ exchange. So, when excreting bicarb, K+ losses simultaneously
* Associated with osteomalacia or poor growth in children
E31. A mildly hypothyroid elderly woman is seen. TSH 10, free T4 ~ 6, anti-TPO Ab positive. On exam, the right lobe of the thyroid is mildly enlarged, firm but non-tender. Next step?
B. I-131 thyroid scan
C. Start thyroxine
D. Observe for 3 months
E. Thyroid ultrasound
* TSH >10
* non-elderly with TSH 4.5-10 and:
-high anti-TPO (predicts progression to overt hypothyroidism) (Consider)
* age > 70, TSH 4.5-8, NO tx. possible CV and skeletal morbidity with tx, uncertain benefit
E32. 55M obese, DM. His HbA1c is 8.3. Cr is 180. He has a history of CHF. What is the best management plan?
B. NPH qhs and metformin
A - metformin contraindicated in stage 4 and 5 CKD (avoid once Cr >150/CrCl <30, caution if CrCl <60)
B - metformin contraindicated
C CORRECT - Repeglinide (Meglitinides) ↓HbA1c by 1-2%, however it causes significant wt gain of 2.3-2.7kg. Safe in CHF and CKD
D - TZD (rosiglitazone and pioglitazone) contraindicated in CHF due to fluid retention
E - glyburide: not recommended in CKD (GFR <50)
E33. A young man admits to steroid use for the past year. He now wants to have children. Which would you expect to find?
A. High HDL
B. Low HDL
C. Large testes
D. High LH/FSH
E. Increased sperm count
E34. 24M complains of weakness while working out at the gym. He has gained weight and has purplish striae (you are shown a picture of this). Labs show a high fasting AM cortisol, high 24 hour urinary cortisol, and high ACTH. There is no suppression with either low or high-dose dexamethasone. What is the most likely cause?
A. Pituitary adenoma
B. ACTH secreting carcinoid
C. Adrenal adenoma
D. Surreptitious steroid use
High ACTH with no suppression with high dose dexamethasone suppression test suggests ectopic ACTH.
E35. Woman with DM for 6 years. Recent admission for MI. HbA1C 0.09, HDL 0.9, TG 2.0, LDL 2.1. What would you give to reduce the risk of another MI?
C. Vit E
E36. 58F with fatigue and mood changes. No other complaints, examination normal. Labs: Ca 2.78, PO4 0.8, PTH 58 (ULN given at 60). Before referring for surgery what other test would you do?
A. 24h urine for calcium
C. Bone scan
D. Vit D levels.
E37. Young F with DKA. Glucose 33, HCO3 8, Cr 138, pH 7.01. He treats her with 5 units per hour of Humulin R, IV NS 500cc/hr for several hours and then 250cc/hr (I think those numbers are right), and some potassium. 12 hours later, glucose is 22, HCO3 is 9, Cr is 128, pH is 7.01. What is true?
A. She has received inadequate IVF
B. She has received inadequate insulin
C. She has developed hypophosphatemia
D. She requires HCO3 IV
A - CDA Guidelines recommend 1-2L/h bolus for shock, then 500cc/h x 4h, then 250cc/h x 4h. Patient is receiving appropriate IVF
B CORRECT - pH is unchanged after 12 hours à insufficient insulin
C - Many patients with DKA develop hypoPO4 with treatment. But hypoPO4 would not explain persistent acidosis and high AG
D - CDA Guidelines recommend 1 amp of HCO3 if pH <7.
E38. 24F who wants to become pregnant presents for assessment of 18 months of amenorrhea. TSH N, B-HCG negative, Prolactin 80ug/L (high). CT head Normal. Next course of managment?
A. MRI pituitary
B. pelvic U/S
* Physiological: pregnancy, breastfeeding
* Pituitary: prolactinoma
* Loss of dopaminergic inhibition of pituitary: Hypothalamic lesion, Pituitary stalk compression, drugs: (antipsychotics, metoclopramide, domperidone, methydopa, verapamil)
* Hypothyroidism → ↑TRH→ ↑prolactin
* Renal and liver failure
* High prolactin ]inhibits GNRH secretion --> low FSH/LH --> low estrogen(F) or testosterone (M)
* Females: Amenorrhea or oligomenorrhea, infertility, galactorrhea
* Males: decreased libido, impotence, infertility, gynecomastia
E39. 70F with breast cancer and mets on tamoxifen presents with nausea, vomiting, and confusion and has an elevated Ca. After volume repletion the next best step is:
* only pamidronate and zoledronate are approved by FDA to tx hypercalcemia
E40. Pt post transphenoidal resection of non-functioning pituitary adenoma. POD # 1: hypernatremia tx w/ DDAVP. POD # 2: Na normal, pt. euvolemic --> IVF changed to 75mL/hr D5W & 0.45 NS. Start hydrocortisone 50 mg q4h. POD #3: pt hyponatremic. What statement is true?
A. DI may develop in the coming week
B. Hyponatremia is due to DDAVP
C. Hyponatermia due to mineralcorticoid deficiency
D. Hyperglycemia is due to steroids
A CORRECT: DI may develop in the coming week. Usually starts 24-48 h post op and lasts 7d if transient, but can also be permanent DI.
B: Unless pt still on DDAVP; if so, would expect concentrated urine. Alternatively, hyponatremia could be due to hypotonic fluids, in which case would expect dilute urine.
C: pt on hydrocortisone
D: hyperglycemia not discussed.
E41. 40F DM2 x 2yrs. Meds: glyburide 10mgbid, metformin 1gbid. no diet or exercise. Non-smoker. Normal menses. ++ famhx: DM2, CAD onset age<50. Obese and BP 130/75. Labs show:HbA1c 12.1, Cr 90, TC 4.8, HDL 0.8, TB 6.8, ACR 5.2, TSH 6.5. Tx hyperlipidemia?
D. Micronized fenofibrate
*TG from underlying poor diabetic control does not respond to lipid lowering agents. need to tx underlying DM
E42. 35M long distance runner. Presents with poor libido but shaves daily. He develops arthralgias on occasion after running. On exam he is tanned with small and mildly soft testes with normal virilization. Low LH, low FSH, low testosterone, TSH normal with free T4 10 and normal pituitary MRI. What test next?
A. Transferrin saturation
B. Urine for anabolic steroids
D. Biopsy testicle
E43. 20F presents with secondary ammenorrhea. She had normal menstrual periods until age 18, and then none since. She has developed acne and temporal hair loss over the past 6 months. Her testosterone is elevated at 9 (upper limit ~2, reference given). Her DHEAS is normal. Her BhCG is negative. What would be your next test?
A. Pelvic U/S
* technically don’t need U/S to diagnose
* Since only testosterone is ↑, not DHEA-S, it’s likely PCOS
* if ↑ 17-ketosteroids, DHEA-S, 17-hydroxyprogestrone, it would be more c/w an adrenal, rather than ovarian, source of excess androgen production
E44. A patient has asymptomatic Paget’s disease. He has one lesion on a rib, but the rest of the bone scan is negative. His ALP is 274, and is Ca is normal. What would you do?
* symptomatic: tx if ALP elevated or if active disease on bone scintigraphy
* asymptomatic + active disease (+ bone scintigraphy or high ALP): tx if disease in skull, spine, weight bearing bones, abutting joint lines). else tx if bone sx @ active sites or if ALP > 2x ULN. Asymptomatic + active disease not meeting criteria, tx recommended for most but can observe if pt pref
E45. A patient on amiodarone develops a tremor and heat intolerance. Labs are done and show a TSH 0.001, T4 25, T3 normal. RAIU 0%. What is the diagnosis?
A. Amiodarone induced hypothyroidism
B. Amiodarone induced thyroiditis
C. Amiodarone induced inhibition of peripheral T4 to T3 conversion and pt is euthyroid
D. Amiodarone inhibition of T3 release from thyroid
46. F DM1 is pregnant. Her BP is normal and the rest of her labwork is normal. She is found to have microalbuminuria. What is the management plan?
A. Start ACE inhibitor
B. Low protein diet
C. Monitor for hypertension
D. Low salt diet
RF progression of diabetic nephropathy: Microalbuminuria, Degree of glycemic control, BP, Pregnancy
* diabetic nephropathy, poor BP control, pregnancy --> risk of preterm delivery
E47. Patient had a carotid U/S that incidentally noted a 0.3cm thyroid nodule. The patient is biochemically euthyroid and does not have any history of XRT exposure or family history of thyroid cancer. What is the appropriate plan?
A. Re-assess in 3-6 months
B. Do radioactive iodine uptake scan now
C. Biopsy now
D. Thyroglobulin level
E48. A young man presents with azoospermia, normal hair distribution growth and puberty. On exam he is 180cm tall, his arm span is 183cm, and his pubis to foot length is 95cm. He has normal secondary sexual characteristics. His testes are small and firm. What is the best diagnostic test?
A. WBC karyotype
B. Testicular biopsy
C. Pituitary MRI
D. Urine for anabolic steroids
Approach to azoospermia
* pre-testicular: secondary testicular failure (low FSH, low testosterone), anabolic steroids
* testicular: primary testicular failure (high FSH, low testosterone), Klinefelter, Y chromosome microdeletions
* post-testicular: ductal obstruction, ejaculatory dysfunction
E49. 56M presents with flushing, diarrhea, telangiectasias. On cardiac exam he has large V waves, a slow y descent, and a pansystolic murmur at the LSB. What is the most likely Dx?
Features of carcinoid syndrome:
* Flushing (85% of patients)
* Telangiectasias (late in the disease)
* Diarrhea (80% of patients)
* Cardiac valvular lesions
E50. A patient with type one DM has mild proteinuria and is on enalapril 5mg PO OD. He does not have hypertension, in fact he has an asymptomatic postural drop from sBP 120 to 110. What is the best intervention to further reduce progression of his nephropathy?
A. Insulin pump
B. Smoking cessation
C. Increase the dose of enalapril
D. Restrict protein in the diet
* strict glycemic control (can delay onset and progression)
* ACE inhibitors (when started at microalbuminuria stage)
* ARBs (in patients with average creatinine 150)
* ACEi = ARBs (as per DETAIL trial)
* weight loss (in obese diabetic patients)
* smoking cessation (this is a risk factor for diabetic nephropathy)
E51. 61 M, DM2 presents with morning hyperglycemia. His AM fasting capillary glucose ranges from 2 to 20. Day sugars are OK. He is on R at breakfast and dinner and on intermediate acting insulin (NPH) 15 U with breakfast and 12 U with dinner. What should be done?
A. Decrease dose of R in AM
B. Decrease NPH at supper and eliminate bedtime snack
C. 3 AM glucose and move NPH to hs if necessary
D. Measure 2h pc meals glucose
A - will not affect fasting sugar
B -possibly be right if his hypoglycaemic episodes occurred when he didn’t have his snack
C CORRECT - we need to know what is happening overnight. moving the NPH to HS will make it more likely to reach the morning
D - this will not help address fasting glucose
E52. 23 F presents with anorexia nervosa. She is 4'11 and weighs 90 lbs. She has evidence of lanugo hair. She is at risk for which of the following?
A. Sudden death
B. Short QT
D. Postnasal drip
E53. 40 F presents with moon facies, easy bruisability, difficulty sleeping and purple abdominal striae. You suspect Cushing syndrome. What is the best investigation to diagnose Cushing syndrome?
A 24 hour cortisol that is 3X ULN
B. 24 hour cortisol that is 5X ULN
C. Elevated AM serum cortisol
D. Depressed AM ACTH
Stats for each diagnostic test for hypercortisolism:
* 24 hour urine free cortisol (3x ULN): +LR 10.6, -LR 0.16
* Salivary midnight cortisol: + LR 8.8, -LR 0.07
* 1 mg dexamethasone suppression test: +LR 16.4, -LR 0.06
E54. 34 F with family history of pernicious anemia presents with fatigue, postural changes, hyperpigmentation especially in intertriginous areas. What is the next best test for diagnosis?
A. Metapyrone test
B. Dexamethasone stimulation test
C. Serum ACTH and cortisol levels
D. Anti-adrenal antibodies
A - Metapyrone: Not routine, used post NSx. For dx adrenal insufficiency & differentiate 1ary or 2ary
B - Dex stim test: non-sensical
C CORRECT - autoimmune adrenalitis: most common 1ary adrenal insufficiency. assoc w/ thyroid, hypogonadism, DM1, pernicious anemia, hypoparathyroidism). AM cortisol (expect <100 diagnostic), ACTH (expect high)
D - adrenal insuff Ab: not for dx of 1ary adrenal insufficiency
E55. 30F presents with a 3 cm thyroid nodule found on palpation. No family history of thyroid dx, no prior radiation. TSH is normal. What is the best management?
A. Thyroxine to suppress
B. U/S of thyroid
C. Fine needle aspiration
D. I131 ablation
E56. 40F presents with Graves' disease and significant ophthalmopathy. RAIU = 90% and TSI positive. How to treat:
A. Subtotal thyroidectomy
B. Radioactive iodine + prednisone
C. Radioactive iodine + orbital radiation
D. Radioactive iodine only
E57. 42F is admitted with DKA. Na 129, K 5.2, Cr 140, glucose 32, HCO3 4, pH 7.01. Which is true?
A. Her total body potassium is not increased
B. Her hyponatremia is most likely on the basis of SIADH
C. Her acidemia is an indication for bicarbonate infusion
D. Treatment of this will result in hyperphosphatemia
A - CORRECT: Total body potassium is depleted due to urine losses, but there is a shift out of cells into the blood due to insulin deficiency
B - Hyponatremia in DKA is pseudohyponatremia from high glucose, nothing to do with SIADH; in fact in DKA any ADH secretion is very appropriate
C - Indications for bicarb in DKA: pH < 7.0 after fluid infusion
D- Phosphate is low in DKA due to osmotic diuresis, treatment will likely not result in hyperPO4
E58. Young male with episodes of sweating, palpitations, headache. BP in between is normal. 3 x 24 hour urines for VMA are in upper limit of normal.
A. Hx + labs enough to r/o pheochromocytoma
B. If catecholamines decrease w/ clonidine, likely pheo
C. If catecholamines don't decrease w/ clonidine, likely pheo
D. Hx is irrelevant to the presentation
Clonidine suppression test: used as confirmatory test
* Clonidine suppresses central catecholamines
* Give clonidine and measure plasma catecholamines or fractionated metanephrines at time 0 and 3 hours after the dose
* Pheochromocytoma is confirmed if catecholamine or metanephrine levels DO NOT DECREASE sufficienty
E59. A diabetic man presents with edema of legs and hands but urine protein only 0.5 g/24h, on rosiglitazone. What is the cause of this?
B. Nephrotic syndrome
C. Congestive heart failure
D. Liver failure
* BLACK BOX WARNING – may increase risk of fatal myocardial infarction
* Adverse effects:
Edema (5%) – also binds to nephron receptors to increase sodium reabsorption
Myocardial ischemia (3%)
E60. 45F post-op total parathyroidectomy. Initial bloodwork indicates serum potassium 2.1 mmol/L, serum calcium (ionized) 0.6mmol/L. She is given replacement iv potassium and calcium stat. Repeat bloodwork 2h later indicate K+ 2.5, Ca++ (ionized) 0.75. What would be the next best step:
A. IV calcium infusion
B. check serum Mg++; replace if low
C. po calcitriol
D. iv potassium infusion
E61. A family physician calls you for advice regarding a mutual patient with recently diagnosed hypothyroidism 2 weeks ago. She has been on L-thyroxine for 10 days and repeat TSH is still elevated. What advice do you offer:
A. Double the dose of L-thyroxine
B. Switch to synthroid
C. Continue the same dose and recheck TSH in 4 weeks
D. Thyroid ultrasound
* 4-8 weeks after initiating therapy
* 4-8 weeks after change in dose or TSH prep
* q6-12 months after stable dose achieved
E62. 24F MEN type 1, prev total thyroidectomy at age 8. Presents palpitations, diaphoresis and headaches intermittently. Thinks that if she drinks juice it shortens duration of symptoms. BP 130/70, HR 80. What is the most appropriate investigation?
A. Urine and/or serum metanephrines
B. 24 hour Holter
D. Glucose and insulin level during one of her episodes
·Men Type1: hyperparathyroid, pancreatic tumour (insulinoma), pituitary adenoma
Her symptoms now may be due to a pancreatic tumour (eg. insulinoma) causing hypoglycemia.
E63. A woman has been on prednisone for 5 months for viral thyroiditis. Now has right groin pain with weight bearing. On exam has right groin pain with passive leg movement. X-ray is normal. What diagnostic test would have highest sensitivity in this problem?
A. Bone scan
B. Hip arthrogram
C. DEXA scan
D. MRI hip
E64. Which one of the following medications is associated with a mortality benefit in a patient with diabetes mellitus?
B. Angiotensin receptor blocker
D. ACE inhibitor
C CORRECT - Metformin: UKPDS 34 demonstrated a 42% RRR in DM related death and 36% RRR in all-cause mortality when compared to diet alone Rx w metformin
D - ACEi: ADVANCE trial (perindopril-indapamide) showed decreased rates of CV mortality, HOPE trial (ramipril) showed reduced mortality in diabetics >55 with a CV risk factor
E65. 22F presents to your clinic requesting OCP. She is well, and has no children. She is sexually active with 2 partners. She smokes 4 cigarettes per day. Her sister had a post-operative DVT, another sister had cervical cancer and her mother has breast cancer. Which of the following is a contraindication to OCP?
A. She has a family hx of VTE
B She is a smoker
C. She has a family history of cervical cancer
D. She has a family history of breast cancer
E66. 38 M has an incidental CT scan which shows a 1.5 cm R adrenal nodule. Which of the following test is unnecessary?
D. Renin and aldosterone values
E67. 23M with a right testicular mass has a CT scan that shows retroperitoneal and mediastinal lymphadenopathy. AFP and BHCG are negative. He proceeds to an orchidectomy. What will the pathology show?
D. Leydig cell tumor
A, B - AFP and BHCG are negative, teratoma and choriocarcinoma are less likely
C CORRECT - seminoma (germ cell tumour) is the correct choice.
D - leydig cell tumour: stromal tumors are much less common than germ cell tumors
E68. Man in his 60s with left proximal tibial pain, which awakens him at night. The area is warm on exam. Plain film shows trabecular thickening. ALP is elevated - mostly the bone fraction. The calcium, PTH and renal function are all normal. Treatment?
A. Pamidronate 90 mg IV qmonthly
B. Alendronate 40 mg po OD
C. Radiation therapy to the affected area
E69. Patient who is known to be depressed also has hypertension. Which of the following is most consistent with the diagnosis of hyperaldestronism
A. Diuretic induced hypokalemia (>2.5 but less than 3)
B. Renal deterioration
C. Hypertensive crisis with the use of Monoamine oxidase inhibitors
D. Hypernatremia (>148)
E70. 50M with abdominal pain. CT abdomen reveals a 2cm adrenal mass/nodule but nil else. His BP is 120/80. 24hr urine for cortisol and catecholamines is negative. What would you do next?
A. repeat imaging in 3 months
B. renin:aldosterone measurement
C. ACTH level and dexamethasone stimulation test
D. FNA of mass
* low-risk of malignancy based on imaging characteristics.
* all patients should have workup for pheochromocytoma and subclinical Cushing’s syndrome, but only those who are hypertensive require hyperaldosteronism workup.
* re-imaged in 3-6 months to assess for growth of the adrenal nodule. A tumour that enlarges by more than 1cm should be removed
Benign size <4cm, smooth border, homogeneous, hypodense, <10 HU attenuation, rapid contrast washout (>50% at 10min), unilateral
Malignant size >4cm, irregular border, heterogeneous, calcifications, >20 HU attenuation, delayed contrast washout (<50% at 10min), bilateral (mets)
* repeat imaging study at three to six months after initial discovery
*repeat hormonal testing q4yrs
E71. 25F ?porphyria. She complains of episodes of abdo pain, malaise and fatigue. She is adopted. Routine biochemistry and spot urinary porphorins are normal. Best test to rule out porphyria?
A. Negative family history
B. Normal random 24 hour urine collection for porphyrins
C. No symptoms related to sun exposure
D. Normal 24 hour urine collection for porphyrins during an acute attack
A - Porphyria is mainly autosomal dominant but has incomplete penetrance; therefore negative family history cannot rule out the disorder
B - Random 24 hour urine: sample best collected during the time of an acute attack
C - Symptoms related to sun exposure typically occur with cutaneous porphyrias
D CORRECT - 24 hour urine collection: obtain during attack
E72. 34F fasting glucose of 6.4. Had GDM in last pregnancy treated with insulin for the last 7 weeks and has hypertension. Current BP is 150/85. She is overweight. She is very concerned about not becoming diabetic. All of the following have been proven to reduce the risk of developing DM EXCEPT:
A. lifestyle change including diet and exercise
B. metformin 850mg BID
C. repaglinide 0.5g TID
D. ramipril 5mg od
E73. DCCT trial has shown:
A. Reduction of retinopathy within the first year
B. Increase in incidence of hypoglycemic events
C. Decreased GFR
D. No change in nephropathy
E. Increased insulin requirements in the tight control group
E74. Man with hypoglycemia, lung mass to diagnose
A. C peptide
B. urine for sulfonylurea
E75. 22F, secondary amenorrhea for 18mo. Menarche @ 12yo. Irregular periods. Obese. Hirsute. WANTS TO GET PREGNANT! She had a withdrawal bleed after a trial of progesterone po. What is the best treatment option for her?
B. Estrogen-cyproterone combination
C. Human chorionic gonadotropin
E76. 45M has big hands, big feet and coarse facial features. He's sweaty but otherwise feels well. The best test to confirm the diagnosis is:
A. IGF-1 levels post 75 g glucose load.
B. GH levels post glucose load.
C. GH levels
D. IGF-1 levels after insulin.
E77. 26F complains of intermittent spells of headache, diaphoresis, and palpitations. She has a cousin who required neck surgery. On exam, she is hypertensive with a blood pressure of 220/110, has a postural drop to 170/80, and has an S4. You would treat her with which of the following to control her hypertension?
E78. 68F who develops excruciating thoracic back pain. She is found to have a T9 compression fracture. Bone density scanning shows osteoporosis at the hip and spine. You recommend:
A. oral bisphosphonates
B. IV bisphosphonates
C. sodium flouride
D. nasal calcitonin
E79. 22y/o female with Type 1 DM x 10yrs. Stable VS included BP 120/80. Has a 24-hour urine protein of 740mg. What will decrease progression of her proteinuria?
A. ACE inhibitor
B. Treat hypertension
C. Glucose control
D. Low protein diet
E80. 25F with Addison’s disease on fludrocortisone and Prednisone. Forgets to take fludrocortisone x 4 days. Presents with lethargy, fatigue. On exam had significant orthostatic change 100/40 to 60/P. Labs reveal low Na, high K (6.3) ECG normal. Best treatment?
A. Lasix and Kayexalate
B. Dexamethasone 4 mg iv
C. Hydrocortisone 100 mg iv
D. 5 days doses of fludrocortisone all at once
A - ridiculous
B - Dexamethasone has no mineralcoriticoid action. unlike secondary adrenal insufficiency, primary adrenal insufficiency requires replacement of both glucocorticoid and mineralocorticoid.
C CORRECT - Hydrocortisone has some mineralocorticoid activity (see chart).
D - 5 days of fludrocortisone all at once likely too much as it could cause hypertension and heart failure.
E81. 60 yo woman with ovarian ca. what is best test to follow disease?
E82. 48M w/ fatigue,burning pain bilat feet x 4mo. c/o low libido, erectile dysfunction. Generalized skin darkening, BP 120/70, HR 74 and BMI 24.1. Decreased vibration sense below the mid-calves bilaterally. Normal genitalia. FBG 8.4, HbA1c 0.067, serum testosterone 4.5 (low), FSH 2, LH 1 (low normal). Dx?
A. Serum ACTH
B. Transferrin saturation
C. Serum free testosterone
E83. 45M 1ppd smoker with new onset weight loss of 15lbs, fatigue, hemoptysis & increasingly tanned skin. Exam reveals BP 160/95 & darkened skin. Workup reveals fasting glc 18 & mass in RUL on CXR. Most likely underlying pathology?
A. adrenal adenoma
B. MRI will show pituitary adenoma
C. CT will show bilateral adrenal hyperplasia
D. He has insulin resistance
E84. Young woman with painful neck. Exam reveals enlarged thyroid, tender. TSH = 0.02, fT4 = 30. What is next?
B - Subacute thyroditis
E85. 50M with new history of hypoglcemic events manifested by tremor, anxiety, blurred vision when he misses a meal. Preliminary workup is negative. You agree to admit him for a 72hr fast. At 12hrs, his glucose is 2.1 and insulin is 21 (N 25-50). What do you check next to make the diagnosis?
B. Sulfonylurea screen
* Hypoglycemia with a low insulin suggests action of an insulin-like factor
* IGF-induced hypoglycemia have low serum insulin and C-peptide concentrations during hypoglycemia
E86. Young pt presents with DKA (pH 6.96 and high AG). Insulin bolus (10u) given and infusion (5u/hr) started. NS is administered. Upon rechecking labs, AG is better but pH only improved to 7.0 What is the cause?
A. insufficient insulin
B. no bicarb was given
C. insufficient potassium
D. insufficient rehydration with NS
Excretion of the sodium and potassium salts of beta-hydroxybutyrate and acetoacetate lowers the serum anion gap without affecting the serum bicarbonate concentration and therefore the degree of acidosis
E88. 70F presents with acute lower back pain. X-ray shows diffusely decreased bone mineralization. She underwent remote partial gastrectomy for PUD. Her lab values are Ca 2.00, PO4 0.8, ALP 140, CR 170 (no PTH or albumin given). Which of the following the most likely diagnosis?
A. Renal osteodystrophy
Gastrectomy is a risk factor for osteomalacia, which is associated with hypocalcemia, hypophosphatemia, and increased ALP.
E89. 55M with a 3 month history of muscle weakness. Examination demonstrates only proximal muscle weakness. Remainder of information is as follows: BP 160/110. Na 138 K 2.2 Fasting serum cortisol 1100, 1600h cortisol 850. What is the most likely diagnosis?
A. adrenal cortex adenoma
B. adrenal cortex carcinoma
C. pituitary microadenoma
D. Ectopic ACTH
E90. 60 year old man with recent TIAs. At ultrasound for his carotids, radiologist finds that he has multiple small thyroid nodules (both glands). The largest nodule measure 0.9 cm. His TSH is normal. What would be your next step in this patient’s management:A. Radioactive uptake scan
< 1cm thyroid nodules in patient’s without a high-risk history should be followed.
E91. Male patient with history of MI/CHF. Diagnosed with DM - sugar control is not optimal. Pt is apprehensive about starting meds because brother suffered hypoglycemia from use of oral hypoglycemic agent. What would you recommend?
Ddx exogenous testosterone
* Adrenal tumour
* PCOS: usually sx amenorrhea, obesity, acne, DM, infertitily and presents at puberty
* Ovarian tumour (sertoli/leydig cell tumour AKA granulosa-theca AKA hilus
E94. Patient with DM2 with an ulcer on the the first metatarsal. Abnormal monofilament and vibratin sense. Diminished distal pulses. Maybe history of macrovascular disease and microalbuminuria (can't remember). What is most important risk factor for the development of ulcers?
A. microvascular disease
B. macrovascular disease
C. impaired immune response
D. peripheral neuropathy
* Neuropathy is present in 80% of patients with foot ulcers.
* Promotes ulcer formation by:
Decreasing pain sensation and perception of pressure,
Causing muscle imbalance that can lead to anatomic deformities
Impairing the microcirculation and the integrity of the skin
E95. True statement regarding PSA
A. not useful in men under 70
B. PPV of value between 4-10 is 22%
* MHLTC does not recommend PSA as pop-wide screening tool in asymptomatic males
* PSA cutoff of 4.0 ng./mL with sensitivity of 21%, specificity is 91%, 51% for detecting high-grade prostate ca’s (ie Gleason >=8)
* PPV - 30%, NPV - 85%
E96. You suspect osteoporosis. What makes osteoporosis more likely
A. teeth count<20
B. Weight <50kg
C. wall to occiput>0
D. arm span>height
E97. Man with nonspecific abdominal pain – Ix showed an adrenal adenoma - what next
A. Check if it is functional
B. MRI will help distinguish between carcinoma and adenoma
C. If <4cm then likely carcinoma
D. If > 6cm - definitely needs surgery
* Cushing - pm cortisol, 24hr urine free cortisol, 1mg dex suppression, low ACTH
* Pheochromocytoma (<3%) - 24hr urine fractionated metanephrines & catecholamines
* Aldosteronomas (< 1%) - plasma renin activity, plasma aldosterone conc
E98. young woman shortly after deliver, breast feeding. Presents with tachycardia, tremors, diarrhea, heat intolerance. thyroid enlarged but non tender. High T4, low TSH, low RAIU (< 1%). Management
* post-partum thyroiditis is destructive thyroiditis induced by autoimmune mechanism <=1 yr pp
* Can present as hyper/hypo or hyper then hypo. Serum TPO Ab high in 60-85% pts
* usually no tx needed during hyper/hypo phase. monitor thyroid q4-8wks. hyper: symptomatic, give propanolol; hypo: symptomatic, give T4
E99. 59F with L hip fracture and demineralization on plain X-rays. Ca= 2.02, PO4 =0.6, PTH=90, normal Cre, no ALP given. All other B/W normal. What is the most likely cause?
A. Vitamin D deficiency (osteomalacia)
C. Primary hyperparathyroidims
E100. 52M with DM2 for the past 20 years. Routine blood work and urinalysis are as follows: Na 135 K 5.0 HCO3 20 Cl 110. sOsm 283. Urine Cl 40 Urine K 20. What is the cause of his lab findings:
A. inadequate insulin production
B. inadequate Na/K ATPase activity
C. hyporeninemic Hypoaldosteronism
D. too much K in his diet
E101. 50M 18hrs postop for transphenoidal removal of non-functioning pituitary tumor. 0.45% saline in D5W IV at 125cc/h, and solucortef 100mcg IV Q8H. Starts to pee 830ml over 2 hours. Labs given as follows: sNa 135 sK 3.8 sCl 100 Bicarb 24 sOsm 282. uOsm 298 uNa 25A. Replace urine output with IV NS
E102. What has been proven to preserve vision in diabetic patients with proliferative nephropathy?
A. Panretinal laser phototherapy
C. Tight Glycemic control
* laser therapy by panretinal photcoagulation: reduces severe visual loss & reduces legal blindness 90% in severe non-proliferative and proliferative retinopathy (Early Treatment Diabetic Retinopathy Study - ETDRS)
* vitrectomy in severe vitrous haemorrhage
* ranibizumab (a humanized recombinant anti-VEGF antibody fragment), off-label intraocular injection of bevacizumab, steroids
* macular edema: diffuse or focal vascular leakage
* nonproliferative diabetic retinopathy: microaneurysms: intraretinal hemorrhage, vascular tortuosity and vascular malformation. can lead to proliferative diabetic retinopathy
* Retinal capillary closure: form of vascular change detected on fluorescein angiography
* severe nonproliferative diabetic retinopathy
* proliferative diabetic retinopathy
* clinically significant macular edema (CSME): retinal thickening based on subjective assessment of area and distance from the fovea (the centre of the macula responsible for high-acuity vision),+/- hard exudates
E103. A type II diabetic on 30/70 checks his glucose once per day. Has background retinopathy. Blood pressure is okay. His labs are as follows: A1c 9.1%, LDL 3.2, HDL 1.2, triglycerides 1.8. Which will slow his retinopathy?
B. ACE inhibitor
C. panretinal photocoagulation
D. change insulin to NPH h.s. and rapid before meal
Only has background retinopathy therefore can slow progression with improved glycemic control
E104. What has been proven to preserve vision in diabetic patients with proliferative nephropathy?
A. Panretinal laser phototherapy
C. Tight Glycemic control
E105. 24F seen for 2 months of secondary amenorrhea, diarrhea and irritability. Snacks on kelp. On exam, she has tremor, proptosis with exopthalmos and a diffusely enlarged thyroid (4x ULN).TSH 0.1, T4 41 (ULN 27). RAUI 6%, diffuse uptake. Tx?
D. radioactive iodine
E106. 18Fwith primary amenorrhea. Tanner stage III breast development. Wt 130 lbs. Ht 5'7. Scant pubic and axillary hair. What is the best way to investigate?
B. serum DHEAS
C. serum LH and FSH
D. serum testosterone
Primary Amenorrhea Ix:
1. Pregnancy test, TSH, FSH, PRL. 2. FSH high: ovarian failure --> karytope 3. FSH normal: anatomic defect --> u/s 4. PRL high, low FSH: prolactinoma --> MRI brain 4. FSH low/normal: chronic anoluvation (PCOS, hypothalamic functional amenhorrea
E107. 24M with 15lb weight loss, presyncope, fatigue. Hyperpigmentation axilla, gums. + orthostatic drop in BP and rise in HR. Na 120, K 5.3. Test to diagnose condition:
A. dexamethasone suppression test
B. serum ACTH and cortisol levels
C. 24 urine cortisol
E108. Thyroid nodule 2cm, asymptomatic, going for FNA, most cost-effective additional test
D. thyroxine level
* 4-6.5% of thyroid nodules are thyroid ca
* RF: children, age< 30 yrs, > 60yrs, hx of h&n rads, family hx
*protective: autonomously hyperfunctioning nodule, multinodular goiters
* Palpable v. non-palpable = risk of being ca
* Higher TSH: independent RF for predicting malignancy > 5.5 TSH assoc w/ > 30% risk
* Malignant - papillary cancer, medullary cancer, thyroid lymphoma, anaplastic cancer, and cancer metastatic to the thyroid.
* Refer to surgery
E109. 17F presents with primary amenorrhea. She has no pubic or axillary hair, and underwent breast development at age 12. Currently, breasts are Tanner stage III. Her vagina ends in a blind pouch. Which of the following would you order to help sort out the diagnosis?
A. WBC karyotype
B. LH, FSH, and estrogen
C. DHEAS and androstenedione
D. 17 hydroxyprogesterone
E110. 20-year-old male with type 1 diabetes on q.i.d. insulin. Hemoglobin A1c6 7%, and generally sugars are well controlled. Triglycerides 4.1, HDL 0.9, LDL 4.2, total cholesterol 6.6. Besides diet and exercise, which would you start?
* 2nd line therapy if statins not effective at reaching LDL<2 would be Ezetemibe, Niacin, Cholestyramine resin
* If TG>10, fibrate should be used to reduce risk pancreatitis
E111. 20F with type 1 diabetes on lispro before meals and NPH at bedtime. Has not seen a doctor or had blood work in two years. Has had diabetes for two years with glucose ranging from 6 to 30, with the average being 10. Which would you order next?
A. Urine microalbumin to creatinine ratio
B. ophthalmology consult
E112. 20F w/ DM1 presents in DKA. Is given 1-2 L of normal saline bolus, then 250 cc/hr normal saline x24hrs. b/w (admission v. 24h later). CBG 19 (28), K 4.5 (6.6), pH 7.15 (7.05), HCO3 12 (7), Na 143 (144), Cr 90 (130) Next?
A. Increase NS w/ bolus then 500 mL/hr
B. Incrase IVF to NS 500mL/hr, add more K
C. Increase IVF rate, change to D5W + 1/2NS + K
D. Increase insulin to 10 units/hr
E113. A man has a family history of periodic paralysis, and has an episode himself. What is the best acute treatment?
A. give him potassium
B. give him calcium
C. give him sodium
* precipitating factors: High carbohydrate meal, vigorous exercise, stress
* autosomal dominant channelopathies with incomplete penetrance
* tx: all (excluding thyrotoxic) are partially treated with carbonic anhydrase inhibitors. low K K & K-sparing diuretics. high K thiazides.
E114. 30F 7+mos tachycardia, palpitations, sweats, weight loss, diarrhea, and heat intolerant. Has exophthalmos, proptosis, chemosis, and tremor. Has significantly enlarged thyroid, diffusely enlarged but not tender. TSH < 0.01, free T4 44, RAIU 6%, diffuse, non-nodular scan. What would you do next?
E115. 28F with hypothyroidism and diabetes for complaints of nausea, watery diarrhea, and fatigue. BP of 115/70 w/ 15mmHg postural drop. CBC and lytes are normal. Her blood sugar is well controlled. Her TSH is slightly above normal (6). What test would you NOT do?
A. ACTH and cortisol
C. Gastric emptying study
D. Serum T3 and T4
Do not assess thyroid function in acutely ill patients unless strong suspicion of thyroid dysfunction. When assessing thyroid function in acutely ill patients, TSH alone is inadequate.
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