A pt with a BMI of 33 c/o fatigue, excessive thirst, and hunger. The NP suspects type 2 diabetes. Which value during initial testing would confirm the diagnosis?
A. Fasting plasma glucose level of 105mg/dL
B. Glycated HgbA1c of 5.4%
C. Oral glucose tolerance testing result of 183 mg/dL
D. Random plasma glucose level of 206 mg/dL
D. Random plasma glucose level of 206 mg/dL
- Type 2 DM screening tests include: fasting plasma glucose level (>126), random plasma glucose level (>200), and an oral glucose tolerance test (2hr blood glucose level >200) with a 75-g glucose load.
- Normal Hgb A1c = <6%.
A pt presents with an episodic headache, sweating, tachycardia, and HTN that has been resistant to therapy. The pt also reports self-limited episodes of palpitations, tremor, and diaphoresis. Based on this clinical presentation, which of the following tests would be MOST helpful for diagnosis?
A. Thyroid panel, including TSH and free thyroxine (T4)
B. Assessment of serum cortisol and adrenocorticotropic hormone (ACTH) levels
C. 24-hour urine fractionated metanephrines and catecholamines
D. Assessment of glycosylated hemoglobin
C. 24-hour urine fractionated metanephrines and catecholamines
-This pt is presenting with the classic triad of pheochromocytoma = episodic headache, sweating, and tachycardia.
- Low risk = pts with resistant HTN and hyperadrenergic spells (self-limited episodes of palpitations, diaphoresis, tremor), in which case a 24-hr urine fractionated metanephrines and catecholamines test is indicated.
- High risk = pts with an incidentally discovered adrenal mass on CT scan, a family hx of pheochromocytoma, a genetic syndrome that predisposes to or a hx of resected pheochromocytoma. First-line tx = measurement of plasma fractionated metanephrines.
- Thyroid panel = helps identify hyper- and hypothyroidism.
- Serum cortisol and ACTH levels help assess for Cushing’s or Addison’s disease
- Glycosylated hemoglobin = Hgb A1c, assesses for diabetes.
On a routine physical exam, a pt is found to have a thyroid nodule. A neck ultrasound reveals a solid hypoechoic nodule of 2cm with irregular margins. Lab results reveal a TSH of 6.2 mU/L. Which of the following diagnostic tests is the NEXT BEST step in evaluation?
A. Fine needle aspiration of thyroid
B. Assessment of serum antithyroid peroxidase antibodies
C. Measurement of serum calcitonin concentration
D. CT scan of the neck
A. Fine needle aspiration of thyroid
- If the TSH level is normal (0.4-4.5) or high, and the nodule meets sonographic criteria for sampling, the next step is an ultrasound-guided fine needle aspiration biopsy, which is the most accurate method for evaluating thyroid nodules and identifying pts for possible sx.
- Fine needle aspiration should be performed in solid and hypoechoic nodules if they are >1-1.5 cm with at least one of the following features: irregular margins, microcalcifications, taller-than-wide shape, macrocalcifications, or peripheral calcifications.
- A thyroid scintigraphy (nuclear-med imaging) is indicated if the serum TSH is low (<0.4) to determine the functional status of the nodule.
The best initial screening test for both hyperthyroidism and hypothyroidism is:
A. Free T4 (thyroxine)
B. TSH
C. Thyroid profile
D. Palpation of the thyroid gland
B. TSH
- Overt hypothyroidism = a clinical syndrome of hypothyroidism associated with elevated TSH and decreased serum levels of T4 or T3.
-Subclinical hypothyroidism = a condition without typical symptoms of hypothyroidism, elevated TSH (>5) and normal circulating thyroid hormone. - Overt thyrotoxicosis = the syndrome of hyperthyroidism associated with suppressed TSH and elevated serum levels of T4 or T3.
- Subclinical thyrotoxicosis = devoid of symptoms, but TSH is suppressed, although there are normal circulating levels of thyroid hormone.
Which of the following findings is associated with diabetic retinopathy?
A. Arteriovenous (AV) nicking
B. Retinal artery narrowing
C. Papilledema
D. Microaneurysms
D. Microaneurysms
- Classified as non-proliferative or proliferative based on the absence or presence of abnormal new blood vessels.
- Non-proliferative = nerve-fiber infarcts (cotton-wool spots), intraretinal hemorrhages, hard exudates, and microvascular abnormalities (microaneurysms, occluded vessels, and dilated or tortuous vessels).
-AV nicking, retinal arterial narrowing and papilledema are ocular effects more specific to HTN.
Which of the following lab results is consistent with a diagnosis of prediabetes according to the American Diabetes Association criteria?
A. Hgb A1c of 5.5%
B. Fasting plasma glucose 128 mg/dL
C. Hgb A1c of 5.9%
D. Blood glucose 135mg/dL 2 hours post 75-g oral glucose tolerance test
C. Hgb A1c of 5.9%
- The diagnosis of prediabetes is based on impaired fasting glucose, impaired glucose tolerance, and hgb A1c.
- A fasting blood glucose of 100-125 is considered prediabetes.
- A fasting plasma glucose of >126 is considered prediabetes.
- A 2-hr plasma glucose value during a 75-gm oral glucose tolerance test between 140-199 is considered prediabetes.
- A hgb A1c of 5.7- <6.5% is prediabetes, a level of >6.5% is diagnostic for diabetes.
A male pt presents with a waist circumference of 100cm (39 in), neck circumference of 38cm (15 in), BP of 150/90mmHg, fasting blood glucose of 140, and triglyceride level of 160. The pt has PMH of DM2, OSA, CKD, and HTN. The pt meets criteria for metabolic syndrome based on what diagnostic parameters?
A. Neck circumference, blood pressure, fasting blood glucose
B. Hx of DM2, BP and triglyceride level
C. Fasting blood glucose, waist circumference, hx of OSA
D. BP, fasting blood glucose, triglyceride level
D. BP, fasting blood glucose, triglyceride level
- Diagnostic criteria for metabolic syndrome include 3 or more of the following: fasting blood glucose >100 or drug tx for elevated glucose; high-density lipoprotein (HDL) cholesterol <40 in men and <50 in women or drug tx for low HDL cholesterol; triglycerides >150 or drug tx for elevated triglyceride levels; a waist circumference >102 cm (40 in) in men or >88cm (35 in) in women; and HTN as defined by BP >130/85 or drug tx for HTN.
A pt presents c/o thirst, polyuria, weight loss, and blurry vision. The random plasma blood glucose level is 226. What step is indicated next?
A. None; diagnosis confirmed based on random blood glucose and symptoms
B. Repeat plasma blood glucose test on a subsequent day for confirmation of diagnosis
C. Check of Hgb A1c to confirm diagnosis
D. Performance of an oral glucose tolerance test
A. None; diagnosis confirmed based on random blood glucose and symptoms
- American Diabetes Association criteria for dx of diabetes = Hgb A1c of >6.5%; fasting plasma glucose >126, 2-hr plasma glucose >200 during an oral glucose tolerance test; and random plasma glucose>200 in a pt with the classic symptoms of DM.
- Classic symptoms of hyperglycemia = thirst, polyuria, weight loss, blurry vision.
A pt presents with c/o fatigue, cold intolerance, weight gain, and constipation. Lab findings are significant for a high TSH and low T4. Based on this clinical presentation which therapy is indicated?
A. Methimazole (Tapazole)
B. Levothyroxine (Synthroid)
C. Radioiodine ablation
D. Propylthiouracil (Propacil)
B. Levothyroxine (Synthroid)
- This pt is presenting with overt primary hypothyroidism based on the presenting symptoms and confirmed by the lab values of high TSH and low T4 value.
- Tx= Synthroid
-Tx of hyperthyroidism in nonpregnant adults includes antithyroid drugs : Methimazole (Tapazole), Radioiodine ablation, Propylthiouracil (Propacil), or sx.
A pt presents with symptoms of anxiety, palpitations, fatigue, and insomnia. On physical exam, extremities are warm and moist, periorbital edema is noted, and the pt is tachycardic. There is diffuse thyroid gland enlargement upon palpation. Which of the following diagnostic lab values can be expected for this pt?
A. High T4 and/or T3; high TSH
B. Low T4 and/or T3; low TSH
C. High T4 and/or T3; low TSH
D. Low T4 and/or T3; high TSH
C. High T4 and/or T3; low TSH
- Hyperthyroidism symptoms = anxiety, emotional lability, weakness, tremor, palpitations, heat intolerance, increased perspiration, and weight loss despite a normal or increased appetite, warm and moist skin, thin and fine hair, tachycardia, muscle weakness, and hyperreflexemia.
- Graves’ disease = exophthalmos, periorbital and conjunctival edema, and a thyroid goiter.
- Hypothyroidism = fatigue, cold intolerance, wieght gain, constipation, dry skin, myalgia, menstrual irregularities, a goiter, bradycardia, diastolic hypertension, and delayed relaxation phase of DTRs
- Primary hypothyroidism = High TSH and low T4
- Subclinical hypothyroidism = High TSH and normal T4.
A pt presents with decreased mental status, hypothermia, hypotension, and bradycardia. The pt is minimally responsive, and the family reports that the pt takes a medication every day for their thyroid. This clinical presentation suggests which diagnosis requiring emergency resuscitation and support?
A. DKA
B. Hyperosmolar hyperglycemic state (HHS)
C. Hypoglycemia
D. Myxedema coma
D. Myxedema coma
- This is sever hypothyroidism, which leads to the slowing of function in multiple organs.
- Hallmark s/s = decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation.
- This is medical emergency and should be treated aggressively.
- T4 level is usually very low, TSH may be high or normal.
- DKA = anion gap metabolic acidosis, ketonemia, and hyperglycemia (serum glucose is less than 800, usually between 350-500), fruity breath, Kussmaul respirations, deep respirations reflecting the conpensatory hyperventilation.
- HHS = uncontrolled blood glucose, but there is no ketoacid accumulation, serum glucose is usually >600, may often exceed 1,000, plasma osmolality is 380 and neurologic abnormalities may be present.
- Hypoglycemia = low blood glucose levels resulting in weakness, tremor, palpitations, anxiety, sweating, paresthesias, dizziness, drowsiness, delirium, and confusion.
Which of the following electrolyte abnormalities may be reflected in a pt with Addison’s disease?
A. Hypokalemia
B. Hyperglycermia
C. Hyponatremia
D. Hypocalcemia
C. Hyponatremia
- Occurs in 70-80% of pts.
- Is a reflection of both sodium loss and volume depletion caused by mineralocorticoid deficiency and increased vasopressin secretion caused by cortisol deficiency.
-Hyperkalemia = occurs d/t hypoaldosteronism- one of the major functions of aldosterone is to promote the urinary excretion of dietary potassium.
-Hypoglycemia =occurs in adults with adrenal insufficiency secondary to adrenocorticotropic hormone deficiency and in those with type 1 diabetes who develop adrenal insufficiency. - Rarely, hypercalcemia may be associated with acute renal insufficiency.
A pt presents with reports of fatigue, cold intolerance, weight gain, and constipation. Physical examination is notable for bradycardia, coarse, dry skin, and slowed DTRs. which of the following diagnostic lab values can be expected in this pt?
A. Low TSH and low T4
B. High TSH and low T4
C. Low TSH and high T4
D. High TSH and high T4
B. High TSH and low T4
- S/s of hypothyroidism = fatigue, cold intolerance, weight gain, constipation, dry skin, myalgia, menstrual irregularities, a goiter, bradycardia, diastolic hypertension, and a delayed relaxation phase of DTRs.
- Subclinical hypothyroidism = high TSH and normal T4.
- Hyperthyroidism s/s = anxiety, emotional lability, weakness, tremor, palpitations, heat intolerance, increased perspiration, and weight loss despite and increased appetite. Low TSH and high T4.
Which of the following hormones stimulates testosterone release by the Leydig cells of the testes?
A. Growth hormone
B. FSH
C. Prolactin
D. Luteinizing hormone
D. Luteinizing hormone
- LH also stimulates steroid release from the ovaries, ovulation, and the release of progesterone after ovulation by the corpus luteum.
- Growth hormone = responsible for growth regulation during childhood, as well as metabolic functions such as production of insulin-like growth factor -1 and increase in gluconeogenesis.
- FSH = plays a role in estrogen production and follicular development as well as in initiation and maintenance of spermatogenesis.
- Prolactin = responsible for milk production and the development of mammary glands within breast tissues.
Which of the following can be used to differentiate primary from secondary adrenal insufficiency?
A. Adrenocorticotropic hormone (ACTH)
B. Serum cortisol
C. Corticotropin-releasing hormone test ( CRH)
D. Insulin-induced hypoglycemia test
A. Adrenocorticotropic hormone (ACTH)
- Primary = an inappropriately low serum cortisol and a very high simultaneous plasma ACTH concentration.
- Secondary/Tertiary = both serum cortisol and plasma ACTH are inappropriately low (cortisol = 5-23, ACTH = 10-60).
- CRH = used to differentiate between secondary and tertiary adrenal insufficiency.
A pt presents with fatigue, weight loss, nausea, skin hyperpigmentation, and postural hypotension. Lab values are significant for serum sodium level of 131, potassium 5.2, and hgb of 9.0. Diagnostic workup reveals a low cortisol and very high plasma adrenocorticotropic hormone (ACTH) level. These diagnostic findings are suggestive of which type of adrenal insufficiency?
A. Secondary adrenal insufficiency
B. Primary adrenal insufficiency
C. Adrenal crisis
D. Tertiary adrenal insufficiency
B. Primary adrenal insufficiency
- Hyperpigmentation is the most characteristic physical finding in pts with primary adrenal insufficiency.
- Not found in secondary or tertiary adrenal insufficiency because corticotropin secretion is not increased.
- Common lab findings = hyponatremia, hyperkalemia, and anemia.
- Pts will have low serum cortisol and a very high simultaneous plasma ACTH concentration.
- S/s of adrenal crisis = shock (tachycardia, hypotension, cool extremities, dehydration).
A pt presents with reports of increasing central obesity, resistant hypertension, facial plethora, striae, menstrual irregularities, and hyperglycemia. A high index of suspicion for hypercortisolism is made based on the multiple clinical features. Initial testing for Cushing’s syndrome includes which of the following?
A. Early-morning salivary cortisol
B. 48-hour urinary free cortisol excretion
C. Overnight 1 mg Dexamethasone suppression test
D. Late-serum cortisol
C. Overnight 1 mg Dexamethasone suppression test
- Overnight 1m Dexamethasone suppression test is gold standard for diagnosing Cushing’s disease.
- Cushing’s = striae, decreased libido, central obesity, weight gain, menstrual changes, facial plethora/round face, hirsutism, hypertension, ecchymoses, lethargy, dorsal fat pad (back of neck), and abnormal glucose tolerance.
- Initial testing = late-night salivary cortisol (2 measurements), 24-hr urinary free cortisol excretion (2 measurements), or the overnight 1 mg dexamethasone suppression test.
Which of the following medications may cause weight gain?
A. Metformin (Fortamet)
B. Empaglifozin (Jardiance)
C. Semaglutide ( Ozempic)
D. Glipizide (Glucotrol)
D. Glipizide (Glucotrol)
- This is a Sulfonylurea, common side effect of this class of drug = weight gain.
A pt with diabetes reports waking up with elevated blood glucose levels. The pt denies evening or night-time snacking and reports following their insulin regimen of basal and bolus insulin. Which of the following can assist with diagnosis and treatment of this pt’s fasting hyperglycemia?
A. Obtaining a blood glucose level prior to eating dinner
B. Performing an oral glucose tolerance test in the morning
C. Checking the blood-glucose level at 3 a.m.
D. Assessing the hgbA1c
C. Checking the blood-glucose level at 3 a.m.
- “Dawn phenomenon” = caused by the diurnal secretion patterns of hormones.
- An increased release of the growth hormone at midnight to 2 a.m. can combat the actions of insulin in the early morning hours, increasing blood glucose in the morning.
- Tx = increasing basal insulin dosing after assessing blood glucose levels beginning at least 3-4 hours after the last meal or snack and insulin bolus, as well as at 3 a.m.
Which of the following is the initial medication of choice for hyperglycemia in pts with type 2 diabetes?
A. Canagliflozin (Invokana)
B. Exenatide (Byetta)
C. Glipizide (Glucotrol)
D. Metformin (Fortamet)
D. Metformin (Fortamet)
- Most recommended because glycemic efficacy, promotion of weight loss, low incidence of hypoglycemia, general tolerability, and favorable cost.
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