Esap 2010

1
Question
{23-year-old woman with a history of a multinodular goiter had a

total thyroidectomy, which
was complicated by postsurgical hypoparathyroidism.For 2 years after
the operation, her calcium
levelswere maintainedby stablereplacementdosagesof calcium carbonate,i000
mg 3 times
daily with meals,and calcitriol,0.25 mcg 3 times daily. Shesupplemented
her calciuL intake
intermittently with an over-the-counterantacid containing calcium
carbonate.She also took
levothyroxine' 125 mcg daily. During a recent pregnancy,her calcitriol
dosagewas decreased
to 0.25 mcg twice daily, and her blood calcium concentrationsranged
from 9.0 to 9.5 mg/dl.
She delivered a healthy baby and had no difficulty breastfeeding.Two
weeks postpartum, she
was evaluatedin the emergencydepartmentfor a severeheadacheand
was found to have a
blood calcium concentrationof 12.8 mg/dL. She statedthat she had not
taken extra dosesof her
prescribed calcium and vitamin D and had not consumedexcess
dairy products, but that she had
continued to use antacidsintermittently.
Laboratory test results from the emergencydepartment:

Sodium : l44mEq/L
Potassium:3.5 mEq1L
Chloride: 103 mEq/L
Bicarbonate:26 mEqlL /:, '
Serumurea nitrogen: 13 mg/dL
Creatinine: l.l mgldL
Calcium : l2.B mgldL
Albumin:3.7 g/dL
Phosphorus:3.4 mgldL
PTH: <3 pglmL
TSH = 2.4 mlUlL
The serum calcium levels normalizedafter intravenoushydration, and

the patient was discharged
home without calcium or calcitriol replacement.
Now, at her follow-up visit I month after discharge,her blood calcium
concentrationsare
normal (8.2 to 10 mgldl-), without calcium or vitamin D replacement.
I4rhichone of thefollowing explains thepatient's postpartum hypercalcemia?

A. Late recovery of parathyroid function
B. Surreptitious intake of antacids
C. PTHrP secretion
D. Primary hyperparathyroidism
E. Hyperthyroidism
Question
2
423-year-old woman is referred by her obstetrician. She is estimatedto
be in the ninth week
of her first pregnancy.She has had type I diabetesmellitus for I I years.
Her control has been
marginal, and her self-managementhabits have been suboptimal with poor
monitoring and poor
follow-up with her physician. She has not seenan endocrinologist for years.
She had no prepregnancycounseling.After she suspectedshe was pregnant,
she began
monitoring blood glucose frequently and taking all of hir insulin doses.
Dispite efforts to achieve
consistentmonitoring and food intake, she has found wide swings in her glucose
values and has
experiencedmany more hypoglycemic episodesincluding I severeepisode
at 3 AM.
ESAP201O_QUESTIONS
11
Shehas no known complicationsof diabetesand has no other medical problems.
MedicationsincludeNPH insulin, 20 units in the morning and 12 units at bedtime.and insulin
lispro, 10 units in the morning and 12 units at the eveningmeal.
Blood pressureis ll9l73 mm Hg, and pulse rate is 81 beats/min.She is 62 inchestall and
weighs 133pounds(BMI : 24.3 kglm2).Findings from physical examination,including eye and
neurologic examinations,are normal.
Laboratorytest results:
Creatinine:0.6 mg/dl
HemoglobinAr":8.loh
Albumin to creatinineratio:8 pglmg
In addition to referring thepatient for appropriate diabetes education, and assumingall options
are readily available, which one of thefollowing representsthe best next intervention in her
insulin management,assumingadjustmentsmust be made daily?
A. Insulin glargine,26 units eachmorning, and insulin lispro, I unit per l5 g carbohydrate,
with a correctionratio of l:30 mgldl-
B. Insulin pump therapyusing insulin lispro at a basalrate of 0.9 units per hour and meal
doses
of 1 unit per 12 g carbohydrate,with a correction ratio of l:40 mg dL
C. NPH insulin, 20 units before breakfast and l0 units before the evening meal, and insulin
lispro, l0 units beforebreakfastand l0 units beforethe eveningmeal
D. NPH insulin, 24 luriritsat breakfast and 12 units at bedtime, insulin lispro, 12 units at
breakfast,16 units at lunch, and 16 units at the eveningmeal, with a correctionratio of 1:30
mgldL
E. Insulin detemir, 14 units before breakfast and atbedtime, and insulin aspart, l0 units per
meal,with a correctionratio of i:50 mgldl-
Question
3
425-year-old patient is referred to you for treatment of thyrotoxicosis. Elsewhere, she was
found to have a goiter, an elevatedserum free To concentration,and a normal TSH concentration.
The referring internist felt he had further confirmed the diagnosis of Graves diseasewhen
he
documentedmildly elevated concentrationsof serum total and free T..
The patient tells you she has palpitations, but the personal history is otherwise unremarkable.
Severalfamily members have been treated for mild hyperthyroidism.
On physical examination,blood pressureis 106/70mm Hg, and heartrate is 100 beats/min.
She has a smooth, symmetric thyroid gland that is enlargedone time the normal size. The rest
of
the examination findings are normal.
Wich one of thefollowing conclusions is correct?

A. Cross-reactivity between human thyroid-stimulating immunoglobulin and endogenous
TSH is an increasinglycommonproblem
B . The patient has subclinical hyperthyroidism
C . The patient has a genetic syndrome of resistanceto thyroid hormone
D. The patient has a familial syndrome of thyrotoxicosis
E. Radioablation of the thyroid gland is the treatment of choice
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4
Question
A 58-year-old man is referred for managementof dyslipidemia. He has a history of coronary
artery diseasethat initially presentedas angina, but he has not been symptomatic since placement
of a stent in the left anterior descending artery 2 yearcago. He also has type 2 diabetesmellitus
and hypertension.The patient has a history of elevatedLDL cholesterol and triglycerides and
was prescribed simvastatin shortly after his stent placement.Four months ago, he was noted to
have abnormalities in plasma liver enzyme levels, and simvastatin was discontinued.Recent
measurementof his lipids shows a return of hyperlipidemia despiterenewed efforts at dietary
restraint.
Analyte 4 Months Ago 2 WeeksAgo

Total choldsterol,mg/dl 161 2s3
Triglycerides, mgldl- 232 2t6
LDL cholesterol,mg/dl 72 t66
HDL cholesterol,mg/dl 4l 44
Alanine aminotransferase,U [, t26 77
Aspartateaminotransferase,U/L 9l 59
Total bilirubin, mgldl- 1.1 1.0
Alkaline phosphatase,U,lL 84 88
Hemoglobin Ak,o 7.1 6.9
The patient quit smoking2 yearsago and drinks fewer than 5 alcohol-containing beveragesper
week. Other medications include metformin, lisinopril, hydrochlorothiazide, and aspirin. There is
no history of hepatitis and results of serologic tests for hepatitis viruses are negative.Abdominal
ultrasonographyshows a hyperechoic pattern of the liver parenchyma,no dilation of the hepatic
ducts, and no masses.
On examination, he is moderately obesewith a BMI of 33 kglm2. Blood pressureis 128179
mm Hg. There is no jaundice, hepatomegaly,or edema.
Wich one of thefollowing is the best next step in this patient's care?
A. Restart simvastatin
B. Prescribefenofibrate
C. Refer for liver biopsy
D. Prescribeniacin
E. Prescribeezetimibe
5
Question
You are askedto seea 28-year-old woman for evaluation of pheochromocytoma.She has been
troubled by spells for the past 18 months.A typical spell startswith a sharp substernalchest
pain (7110in severity), and it progressesto the point that she feels like "my heart is going to
burst out of my chest." She sensesincreasedbody heat and there is diffuse diaphoresis.Her face
becomesflushed. The only other associatedsymptom is an occipital headache.If she checks her
blood pressureduring a spell it is increased(eg,170190 mm Hg). The durationof the spell is 15
to 20 minutes, and they occur 2 to 3 times per week. Following a spell, she has extreme fatigue
and tries to lie down for 2 to 3 hours. Triggers or alleviating factors for her spells have not been
identified. She does not experienceany senseof doom or panic with a spell.
She is a registerednurse and has carefully documentedher evaluations.Her diagnostic
testing has included 24-hour urine collections for fractionated metanephrinesand fractionated
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catecholamineson 5 separateoccasions,and all values have been normal. Four of the urine
collections were done at the time of typical spells. Plasmafractionated metanephrines
have been measuredon 4 occasions,and their values have also been normal. Imaging has
included CT of the abdomen and pelvis, MRI of the abdomen,MRI of the neck, andlrrl-
metaiodobenzylguanidinescintigraphy.All imaging was normal and did not disclose a
pheochromocytomaor a paraganglioma.An electrocardiogramobtained during a spell was
normal. She has also completed cardiac exercisetesting and a coronary angiogram-findings
werenormal.
Her current medications include metoprolol, 50 mg daily, and phenoxybenzamine,l0 mg
twice daily.
On physical examination,BMI is 37.1 kg/m2,bloodpressureis 125185mm Hg, and heart
rate is 70 beats/min. She is overweight in a symmetric fashion. Finclings from heart and lung
examinationsare norlnal. There are no physical stigmata of familial pheochromocytoma.There
are no renal artery bruits, and her peripheral pulses are intact.
Wich one of thefollowing is the best next step in evaluatingfor pheochromocytoma?

A. order somatostatinreceptor scintigraphy with lrrln-DTpA-pentetreotide
B. Perform systemicvenous sampling for catecholamines
C. No further testing for pheochromocytomais needed
D. Order cardiac-gatedMRI of the heart
E. Order 6-[t8F]fluorodopaminepositron emission tomography
Question
6
You are askedto evaluateand counsel a 45-year-oldman with a 3O-yearhistory of type I

diabetesmellitus. The patient has been on a multiple daily insulin injection program ior the past
15 years, although his glycemic control has been variable. He has had multiple microvascular
complications including retinopathy,peripheral neuropathy,and diabetic nephropathy.The
latter has progressedto the point that he has required dialysis for hyperkatemia on 2 occasions,
and kidney donation from a living related donor is planned in the coming weeks. pancreas
transplantationhas been suggestedbecauseof 2 recent episodesof severehypoglycemia where
the patient was found unresponsivewith subsequentcognitive impairment
Findings on physical examination include the presenceof laser photocoagulation scarsin
the retina of the right eye and diminished vibration and touch sensationbelow the ankles.There
is no orthostatic hypotension, and he has a normal heart rate responseto a Valsalva maneuver.
Normal bowel soundsare present.
As an expectedoutcomeofpancreas transplantation in this patient, which one of thefollowing

statementsis accurate?
A. Normal adrenergicand pancreaticresponsesto hypoglycemia will be restored
B. Glucagon secretionafter pancreastransplantationwill be abnormal
C. Retinopathy will stabilize
D. Graft survival after pancreastransplantationalone is worse than simultaneousor sequential
kidney and pancreastransplantation
E. The 3-year survival rate of the transplantedpancreasexceedsg5%
14 ESAP2010-QUESTTONS
A 1S-year-oldadolescentgirl is referred for evaluation of primary amenorrhea.She statesthat
breastdevelopmentbegan at age 10-6112 years, but notes that her breastshave not changedmuch
in the past 3 years.Pubic hair growth began atage 1l years.Shereportsno hot flashes,fatigue,
cold intolerance,hirsutism, or dry skin. She has experiencedsome teasing about short statureand
level of sexual development.She reports that she has never been sexually active. Her medical
history includes recurrent otitis media, and there is no history of head trauma or central nervous
systemlesions.
Sheis 59 inchestall and weighs 126 pounds(BMI : 25.4kglm2).There are no physical
stigmataof Turner syndrome. Breast developmentis Tanner stage3, and pubic hair is Tanner
stage4. The clitoris and introitus are nofinal in appearance,and there is no vaginal discharge.A
bimanual examination is not performed. The rest of the physical examination findings are normal.
TSH: 1.5mIU/L
FreeT, : 1.2 ngldL
FSH : 64.3IUIL
Eshadiol (ultrasensitiveassayby liquid chromatography-
tandemmassspectrometry):6pglmL
IGF-1 :412nglmL
Karyotype (peripheralblood) :45,X (21 of 30 cells counted)l46,XX
Radiograph of the left hand is interpreted as bone age between 14-6112and 15 years (chronologic
age,15-2112years).Transabdominalultrasonographyshowsa small uterus.
Which one of thefollowing is the best next step in this patient's care?
A. Recombinant human growth hormone, 3.8 mg injected subcutaneouslydaily
B. Transdermalestradiol,12.5mcg daily
C. Recombinant human growth hormone, 0.2 mg injected subcutaneouslydaily, and transdermal
estradiol,100 mcg daily
D. Recombinanthuman growth hormone, 3.8 mg injected subcutaneouslydaily, and transdermal
estradiol,12.5mcg daily
E. Transdermalestradiol, 100 mcg daily, and oral micronized progesterone,200 mg daily on
cycle days 20 through 30
8
Question
A 66-year-old man develops a severeheadacheand double vision. MRI shows a pituitary

adenomawith evidencethat it contains blood. Historically, he has had decreasedlibido, some
symptoms of hypothyroidism, and a low total To concentrationof 4.8 pgldL. Levothyroxine,
50 mcg daily, is prescribed.His serum testosteroneconcentrationis below normal (243 ngldL),
and his serum cortisol concentrationrises to 28 trtgldLafter cosyntropin administration. The rest
of the workup findings are consistentwith a nonfunctioning pituitary adenoma.He undergoes
transsphenoidalremoval of the tumor, and his vision improves. He had no obvious immediate
postoperativesequelae.
One week after the operation, he begins to feel tired and nauseatedand returns to the
hospital.
H$Ap?O10*QUHSTTONS
15
Serum sodium : 116 mEqlL
Serumosmolality :243 mOsmkg
Urine osmolality: 777 mOsmkg
Urinary sodium:31 mEq/L
Serumcortisol :21 pgldL
By the time he is admitted,he is vomiting and confused.He is treatedwith3%osaline(100

mLlh). Aftet 12 hours, his serum sodium concentrationincreasesto 120 rnEqlL,but he has
developedsome crackling rales on chest examination
Llthichone of thefollowing should you do now?

A. Give dexamethasone
B. Administer conivaptan
C. Treat with chlorpropamide
D. Startdemeclocycline
E. Restrictfluid intake to 1500mL per day
9
Question
A 7O-year-oldman is admitted to the hospital for weight loss, failure to thrive, and diffuse boney
pain. A bone scan demonstratesmultiple metastaticlesions with increaseduptake to ribs, femur,
and multiple vertebrae.Attempts to identifiz the primary tumor are underway.Admission serum
creatinine and calcium levels are normal. Zoledronic acid,4 mg, is administeredintravenously.
Approximately 6 days after starting zoledronic acid, the patient describesnumbnessof his lips,
tongue, hands,and feet. Thus, laboratory tests are ordered.
Laboratory test results:

Sodium: t39 mEq1L
Potassium:3.9 mEq1L
Serumurea nitrogen: 18 mgldL
Creatinine:0.9 mgldl-
C a l c i u m: 6 . 2 m g d L
Albumin :3.2 gldL
PTH:250pglmL
25-Hydroxyvitamin D : 28 ng/mL
Which one of thefollowing is the most likely primary malignancy?

A. Prostate
B. Myeloma
C. Thyroid
D. Renal
E. Liver
Question
10
447-yeatold man visits your office with questionsregardingerectiledysfunction.His medical

history is unremarkable.He has recently remarried, and over the past year he has noticed
problems maintaining an erection. He and his wife are considering having children in the near
future. He has normal libido and normal morning erections.He reports no hot flashesor changes
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in shaving frequency.He has discussedthe use of tadalafil with his primary care physician who
suggestedan evaluation by an endocrinologist before starting the medication.
He takesno medicationsother than an 81-mg aspirin tablet daily becausehis father and
uncle had coronary disease.Both his father and uncle were smokers,but the patient does not
smoke.His surgicalhistory is remarkablefor an appendectomyas a child. He has no allergies.
He fathered 2 children with his first wife. His primary care provider obtained a resting
electrocardiogramwith normal findings and a nuclear exercisestresstest, which was also normal
without anginaor evidenceof ischemia.
On physical examination,he is in no apparentdistress.Vital signsinclude blood pressureof
122178mm Hg and pulse rateof 66 beats/min.He is 69 inchestall and weighs 154 pounds(BMI
:22.7 kglm2). Physical examination findings are normal. On genitourinary examination, he has
normal male escutcheon,phallus,and testes.
TSH: 1.4nIUIL
Total testosterone: 584 nsldl-
Which one of thefollowing parameters may be altered if he were to begin treatment with
tadalafil?
A. Sperm count
B. Spermmorphology
C. Testosteroneleve-
D. Exercisestresstest echocardiographiccontractility
E. Blue/sreencolor discrimination
11
Question
You are seeinga 51-year-oldman who initially reporteddiscomforton swallowing and

tendernessin the right anterior lower neck about 1 month ago. He visited his primary care
physician,who prescribedan antibiotic that did not improve his condition.Two weeks ago,
the discomfort and tendernessshifted to the left lower anterior neck, and he experiencedsome
shooting pains up the neck to the angle of the left jaw and into the left ear.He returned to his
primary care physician, who noted a tender thyroid gland on examination and referred him to
your office.
Furtherhistory revealsthat his healthhad been excellentbeforethis illnessbegan.However,
during the past month, he has experiencedfatigue,a poor appetite,a 4-poundweight loss, and
occasionallow-gradefever and headache.He reportsno family history of thyroid disease.
On examination,heartrate is regular at 92beatslmin,blood pressureis 148/56mm Hg,
and temperatureis 99.7"F.He weighs 169 poundsand is 7l inchestall (BMI :23.6kglm'z).
He has a stare and minimal lid lag, but no signs of Graves orbitopathy. He has a fine tremor of
the outstretchedfingers. His thyroid gland is firm, nodulaq and enlargedasymmetrically-the
left side larger than the right, with an estimatedweight of 40 g. The left side is tender without
radiation of pain to the lateral neck or ear.Findings from cardiac examination are unremarkable.
Deeptendonreflexesare brisk.
FreeTo : 3.4 ngldL
TSH: <0.01mIU/L
Completeblood cell count, normal
Routineblood chemistries,normal
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Wichoneofthefollowingtestswouldmostspecfficallyconfirmyourclinicaldiagnosis?
rate
A. Assessingerythrocl'te sedimentation
B. Measuring thyroperoxidase antibodies
iodine uptake
C. Performing Z,4-houtradioactive
D. Performing thyroid ultrasonography
E. Measuring serum thYroglobulin
12
Question
A45-year-oldmanisbroughttotheemergencydepartment.by_ambulance'Heisstuporous, medical technician

confused,combative *t and orl"rri"O *ty to self' the emergency
In the
"ri*or.rr"d, the ambuiance'The patient reeks of alcohol'
statesthat the patient had a brief s eizurein pH,7.22;Pco,,20
gas revealsthe following values:
emergencydepartment,an arterialbtooo
mmHg;andPo,,l2ommHg.Fingerstick-bloodglucoseconcentrationislessthan40meldL examination'
dipstick urinalysis i. ,;gi;posii re for ketoneswith no crystals on microscope
of dextrose 50o/oin
studiesand administer 50 mL
You obtain venous blood for chemistry the next 30
mental statusimproves only slightly over
water (D50w; intravenously.The patient's administer
grotot" concentraiionis 180 mg/d1-'You
minutes,and a repeatedfingerstickblood output is 150 mLAt'
further improvement. Urine
anotherbolus of 50 mi os"ow with no

Creatinine: 1.0mg/dl
:
Serum bicarbonate 15 mEq/L
Serumchloride:98 mEq/L
Serumglucose: 55 mg/dl
:
SerumosmolalitY 370 mOsm/kg
:
Serum Potassium 5'0 mEq/L
Serumsodium :139 mEqlL
Prothrombin time : 12 s
Serumurea nitrogen: 12mgldL
statusafter
bestaccountsfor thepatient'smental
which one of theJbllowing explanations
e'/
administration of intravenousglucos
A. EthYleneglYcol ingestion
B. Alcoholic ketoacidosis
C. HYPerosmolarsYndrom
D. Aicohol-induced hYPoglYcemia
E. Alcoholintoxication
13
Question
manis foundto havea serumcalciumconcentration
In the courseof routine cafe,a25-year-old
of11mg/dl.Heweighsl86pounds.u"i.a,y-ptomatic,doesnottakevitamins,andhasno
historyof kidneYstones'
Laboratorytestresults:
Phosphorus:3.0 mg/dl
Albumin :4.0 gldL
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Alkaline phosphatase: l2}UlL
PTH: 49 pglmL
1,25-Dihydroxyvitamin D, : 46 pgl mL
25-Hydroxyvitamin D : 30 nglmL
Urinary calcium :50 mgl24h
Urinarycreatinine:1.4 gl24h
Wich one of thefollowing is the most likely diagnosis?

A. Sarcoidosis
B. Hypercalcemia of malignancy
C. Familial hypocalciuric hypercalcemia
D. Primary hyperparathyroidism
E. Vitamin D intoxication
14
Question
A 5O-year-oldwoman was recently dischargedfrom the hospital after being treated for an episode
ofpancreatitis. She rarely drinks alcohol, does not have gallstones,and has had no previous
episodesof pancreatitis. She has been taking conjugatedestrogensfor the past 3 months to treat
climacteric symptoms.
Shehaslong-standingobesity;mild diabetesmellitus with a hemoglobinA," level of 6.2%o
while taking no glucose-lowering medication; and hypertensionfor which she takes 25 mg of
hydrochlorolhiazide,25 mg daily, and felodipine, 5 mg daily. She does not smoke cigarettes,but
hasa sedentarylifestyle, rarely walking more than one-half block at a time. There is no family
history of hyperlipidemia or premafurecoronary heart disease.
Sheweighs208 poundsand is 65 inchestall (BMI :34.6 kg/m2).Raisedpapuleswith white/
yellow centersare presentover her buttocks, upper thighs, and extensorsurfacesofher arms.
Findings from the heart examination are normal. She has bilateral femoral bruits and decreased
lower extremity pulses.
Laboratorytest results at hospital admission:

HDL cholesterol: 20 mgldL
Total cholesterol: 500 mg/dl
Triglycerides : 5000 mgldL
Glucose: 140 mgldL
Laboratorytest results the morning of hospital discharge:

Total cholesterol: 295 mgldL
Triglycerides: 978 mgldL
Glucose: l32mgldL
Shewas dischargedon a low.fat, calorie-restricteddiet and metformin, 500 mg daily.
Whichone of thefollowing is the best next step in management?

A. Add simvastatin
B. Add fish oil
C. Add metformin
D. Discontinueestrogen
E. Discontinuethe thiazide diuretic
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15
Question
A 35-year-oldman with a diagnosisof autisticdisordersincechildhoodis admittedto the

orthopedic service becauseof a hip fracture sustainedas a passengerin an automobile crash.
Sincebeing admittedto the hospital48 hours ago,he has had persistenthypernatremia
(sodium, 150-154mEq/L). He has beeningestinglarge amountsof water and voiding large
quantitiesof urine. He hasbeenreceivingcontinuoussalineinfusionssinceadmission(5 L in the
first 36 hours).
The patient is withdrawn and unable to provide a meaningful medical history. His family
sayshe has always ingested large amounts of water and frequently voids large volumes of urine.
He takesno medications.
Measurementsof urine osmolality from specimensobtained randomly during this
hospitalization range from 75 to 100 mOsm/kg. Severaltrials of desmopressin,2 mcg
subcutaneouslytwice daily, do not correct the hypernatremia,and the urine osmolality does not
rise above 100 mOsm,/kg.
On examination, you identiff a contusion over the right frontal area of the head. Other than
the hip fracture, there are no abnormalities.
Wich one of thefollowing is the most likely causeof thepolyuria?

A. Central diabetesinsipidus due to head trauma
B. Nephrogenic diabetesinsipidus
C. Overzealousadministration ofNaCl-containing solutions
D. Inadequatedosing of desmopressin
E. Psychogenicpolydipsia
16
Question
You are askedto evaluate a 54-year-old man with a 40-pack per year smoking history after he
presentedto the emergencydepartmentwith polyuria and polydipsia. The glucose concentration
from a randomly drawn blood samplewas 280 mgldL, and after rehydration he was advised to
seea diabetologist. He has been otherwise well with normal activity and appetite,but reports
a 20-poundweight loss over the preceding2 to 3 months.He is not taking any medication.
He drinks 2 servings of alcohol daily. His family history is remarkable for the development of
diabetesin 1 grandparentin late middle-age.
Examinationrevealsa healthy appearing,middle-agedman who has no evidenceofjaundice
or pallor. Findings from cardiopulmonary and abdominal examinationsare unremarkable.He
currentlyweighs 187 pounds(BMI:25.5kg1m2).

Sodium:137 mBqlL
Potassium:3.9 mEQL
Fastingglucose: 164 mgldL
HemoglobinAr":7.5o/o
Total cholesterol : 230 mgldL
Triglycerides : 150 mgl dL
Alanine aminotransferase: 45 VIL
Alkaline phosphatase : 165UIL
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Wich one of thefollowing is the best next step in the evaluation of this patient?
A. Measureserumcortisol andACTH
B. Perform CT scan of the abdomen
C. Measure glutamic acid decarboxylaseantibody titer and fasting C-peptide
D. Measureglucagon-stimulatedC-peptide
E. Measuretotal iron-binding capacity and ferritin
17
Question
{2i-year-old woman is referred by a general internist. She is an avid runner who has noted
gradually progressivegrowth of facial and body hair over the last l0 years. She removes hair
by shavingas needed.Shealso has noted scalphair loss. Shehas irregularmenses.The patient
hasneverbeen obese,her weight is stable,and her generalhealth is excellent.Shedoesnot
drink alcohol or smoke cigarettes,and she is not depressed.The patient statesthat she does not
useanabolicsteroidsand doesnot take medications.Her exercisetoleranceis excellentand she
continuesto run 3 miles daily.
On physical examination,she is 64 inchestall and weighs 120pounds(BMI : 20.6kgl
m2).Blood pressureis 144196mm Hg. Findings from her examinationare normal, exceptfor
moderatehirsutism in an androgen-dependentpattern. She has mild male-patternbaldness.The
following findings are not present: dorsocervical fat pad, supraclavicular fat pads,plethoric
facies,proximal muscleweakness,thin skin, and thick purple striae.

SerumACTH: 132 pglmL
Serumcortisol concentrations:8 AM result: 44 trtgdL,4 PM result :28 pgldL
Serumcortisol (overnight 1-mg dexamethasone suppressiontest) : 10 pgldl.
DHEA-S :735 ytgldL
17-Hydroxyprogesterone: 100 nglml.
Serumprolactin: 11 ng/ml
Serumtotal testosterone: 100 ngldl-
Serumpotassium: 3.4 mEq1L
Serumsodium :144 mE(L
Plasmaaldosterone: <4 ngldL
Plasmarenin activity : <0.6 nglml- per h
Urinary cortisol excretion:4901tg124 h (urine volume, 1.8 L)
Axial CT imageof the adrenalglands
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Which one of thefollowing is the most likely diagnosis?
A. Cushingdisease
B. Pseudo-CushingsYndrome
C. Familial glucocorticoidresistance
D. Psychological stressrelated to the medical evaluation
E. Exogenousglucocorticoiduse/abuse
18
Question
recently had an
A 30-year-old woman has had 3 first-trimester spontaneousabortions. She
visit to the obstetrician, she reported
uneventful term pregnancy.At her 6-week postpartum
her, and the findings
nervousness,anxiety, and difficulty sleeping.Her obstetrician reassured
were completely
from her physical examination, which was limited to a pelvic examination,
normal.The patientwas scheduledfor a 6-month postpartum visit.
fatigue' and
At the 6-month postpartum visit, she had gained 20 pounds, reported extreme
pufff eyes and
was depressed.Physical examination revealed a somberyoung woman with
thyroid gland and
a firm, slightly enlarged,nontenderthyroid gland. Becauseof the enlarged
symptomJsuggestiveof hypothyroidism, she was referred to an endocrinologist'
Thyroid function test results:

SerumTSH: 49 nIUIL
Thyroperoxidaseantibodies: l7 5 IU lmL
SerumfreeTo:0'3 ngldl
Thyroglobulin antibodies,undetectable
Wich one of thefollowing managementstrategiesshould you recommend?

A. Reevaluatethe patient in 3 months
B. Prescribelevothyroxine, 100 mcg daily by mouth
C. Perform 24-how radioactive iodine uptake
D. Refer to a PsYchiatrist
E. Perform fine-needleaspiration biopsy of the thyroid gland
19
Question
blurring of near
A 55-year-old man who has had tlpe 2 diabetesmellitus for 10 years describes
neuropathy,
and distant vision in both eyes forihe last month. He has a history of mild distal
and microalbuminuria. Medications include
hypertension,background diabetic retinopathy,
lisinopril, 10 mg once daily;
giyburide, 10 mg once daily; 70130insulin, 30 units before supper;
simvastatin, 5 mg at bedtime; and aspirin, 81 mg daily'
his primary care
Blood pr".r*. is 150/85 mm Hg. On undilated funduscopic examination,
hemorrhages, proliferative changes'
physician saw some microaneurysmsand exudates,but no
otttn". abnormalities.Arecent hemoglobinA,. measurementis 9.1%.
Whichone of thefollowing explanationsmost likely accountsfor his visual dfficulties?

A. Malignant hYPertension
B. Retinal detachmentdue to an acuteretinal hemorrhage
C. Cataracts
D. Lens changesdue to variable hyperglycemia
E. Macular edema
22 H$Ap201O*QUH$TIOFI$
20
Question
427-yeatold woman seekstreatment for amenorrheaand infertility. She and her husband
have been trying to conceive for the past 6 months without success.She had axillary and
pubic hair developmentat age ll to 12 years,but has never had spontaneous menses.Shewas
told she had a very small uterus and would not be able to have children. She was treated with
hormone replacementtherapy (estrogenplus progestin) until age25 years, and had normal
breastdevelopment during that time. Amenorrhea recurred after the estrogenand progestin were
stopped.Shehas no anosmia,hirsutism,acne,galactorrhea,headaches,and vasomotorflushes.
Shedoesnot exerciseand hasno history ofan eatingdisorder.

LH: <O.8IU/L
F S H: < I . 9 I U I L
Estradiol: <20 pglmL
TSH and prolactin concentrationswere within the referencerange, and MRI was normal.
Which one of thefollowing is the most appropriate next stepfor this patient who desires
fertility?
A. Clomiphene citrate
B. Observation for 6 more months
C. PulsatileGnRH
D. Exogenousgonadotropins
E. Stressmanagement
21
Question
A 30-year-old man is referred to you by his primary care physician becausea serum calcium
concentrationof 8 mg/dl was noted on a routine chemistry survey.He reports that he had
musclecrampsas a child, but has experiencednone sincechildhood.He reportsno paresthesias.
Intelligenceis normal. He has no bowel complaints,and his weight and height are normal. He
has had no neck surgery and takes no medications.He occasionally drinks alcohol and does not
smoke.No one in his family has had a low serumcalcium level or seizures.Findinss from his
physical examination are normal, including his body shape.
Laboratory test results (blood drawn while fasting):

1,25-DihydroxyvitaminD, : I 6 pglmL
25-Hydroxyvitamin D : 25 ng/mL
IntactPTH:8 pg/ml
Albumin:3.7 gldL
Calcium:8.1 mg/dl
Creatinine: 1.0 mg/dl
Magnesium: 1.6mg/dl
Serumurea nitrogen: 8 mg/dl
Urinary calcium :200 mgl24 h
Urinary creatinine:1.8 gl24h
F$ApASlS*&UEST|0'SS23
wich one of thefoilowing strategies
is the most appropriate cotlrse oJ.action?
A. ric.adenosine
Y::::: antigliadin
:'.-T,? :f antibodies monophosphate
(cAMp)afterintusion
ion of
c PTH
B. Measure
C. Begintherapywith l,2s-dihydroxyvitamin
D, andcalciumcarbonate
D. Instructaboutsymptomsof hyporut."-iu,
Uuigive no othertherapy
E. Beginmagnesiumoxidetherapy
Question
22
vouaboutapalient
withtuberculosis
shewascaued
*::i:r,-J:il#_t""1"H,j'::::::,:"'"13
j1r::;:l*,,1:TT"dt"*,"us_"i,r",il;;;i.*ffi,;ffi
to Okinawa lanqn qnA tr,^^ -^a--^r 'r
i;J,ffifi;:T,XH:li::
to
[,:]ti:#;
3y1 I
haveea nylm-onary
,-s.'v'.rJ infiltrateano
rrr'rlrare unanac
t uOaa postttve
posiri reaction on a purified
JnTH
skin test' He received 4 weeks of protein derivative
antimycobacterial theraov
therapy in c)kinawc
Okinawa and
anrr has
hoo *o*^i-^r ^-
remained on
fi:'ilTJJffi ;"T3.?Tii,"
*:Hl1*1yllf:;,*i",ia,,ia*pi,i,4ii""ffi;,#,fi
i#i::;l"Jd;il1:
ffi::ffl"?:**lriT.unophenyrephri;il;il;i;_"#;#:"iil.':H:ffi
:t""r#f
frllffif"11:1H:::.",1'-.::::i*;ffi;;,iil.;:ffi
ovolactovegetariandiet. :fJ:-#
Although the patient has no history
of thyroid-gland enlargement,your colleague
nontendergoiter' She wants to know found a
how often tub-erculosisin-*tu", the
colleague also reports that the patient thyroid gland. your
has felt fatigued uno tru, u""n constipated
serumTSH in the past
concentration
is27 mru/L, andalowtiterof thyroglobulin
ilfji;J* antibodyis
cau:esis mosttvriketvresponsibtefor
thepatientbhvpothvroidism)
T',t'!,:::{'!:!,'j"::r
A. Rifampin and Hashimoto
2
thyroiditis
B . Nutritionalgoiterwith hypothyroidism
C. Metastaticmycobacterial infectionof the thyroidgland
D. Ibuprofen
E. Isoniazid
Question
23
A 56-year-oldmanhasdifficulfy reading
signs
while driving andhasbilateraluisuAn"]J
defects.He hasalsobeentroubledby increased
thirst andurinationthat causedintemrption
in sleep.He is referredto a neurosurgeon
and
an endocrinologist.The endocrinologisttests
hypothalamic-pituitary function.
Serumsodium: 146m&ql1L
Urinespecificgravity: L004
FreeTo:0.9 ngldL
TSH = 0.4 mIrJ/L
Prolactin:37 ng/mL
IGF-I: l02ng/mL
SagittalMRI imaee.
24 *$Ap3s{{}*&$"i
ff$?isr$s
Serumcortisol before and 60 minutes after cosyntropin: a pg/dL and l9 ltgldL
LH = 3.0IU/L
FSH: 2.OIUL
Serumtotal testosterone:230 ngldL
He is given desmopressinand corticosteroidsand undergoesa transcranialoperation, which

resultsin subtotal removal of the tumor. His vision improves partially, but I year after operation
MRI revealsfumor regrowth.
Whichone of thefollowing is the best next step?

A. Transsphenoidaloperation to remove the remaining tumor
B. Octreotidelong-acting release
C. Stereotacticradiotherapy
D. Systemicchemotherapy
E. Temozolomide
24
Question
A 20-year-oldman is referred to you for evaluation of delayed sexual development.He grew

normally relative to other siblings, but never had a "growth spurt." Moreover, he has not
startedshaving.He is not sexually active. His medical history is also remarkable for bilateral
cryptorchidism,repaired within the first 2 years of life.
On physicalexamination,heis 72 inchestall and weighs 150 pounds(BMI : 20.3 kglm2).
Arm spanis 75 inches. He has few facial hairs, female-patternescutcheon,and no palpable breast
tissue.Phallus is 6 cm and testes are2 mL each.The patient has a markedly impaired senseof
smell.
Completeblood cell count, normal
Blood chemistries,normal
Serumtotal testosterone: 10 nsldl
LH: O.3IU/L
FSH:0.3 IU/L
Serumprolactin: 10 nglml
MRI of the head reveals normal hypothalamic and pituitary structures.
Whichone of thefollowing statementsis true about this patient's clinical disorder?

A. If he were to have an X-linked disorder, all daughterswould be obligate carriers and would
manifest apartial defect in reproductive function
B. Fertility can be induced by administration of low-dosagetestosterone
C. The syndrome is familial in more than9}oh of cases
D. The primary defect is the failure of the gonadotropecells within the pituitary gland to
respondto GnRH
E. Other manifestationsseenin individuals with this disorder include skeletal defects
(syndactyly), cleft lip and/or palate,and unilateral renal agenesis
ffi$&p?s'$s**[JtrsY$*],,s
25
Question
25
444-year-old woman is referred to you for a secondopinion. The patient is questioning whether
she needscontinued insulin therapy for type I diabetesmellitus.
Type I diabeteswas diagnosed4 years ago when a follow-up evaluation after her second
pregnancy revealeda fasting glucose concentrationof 134 mgldL and a hemoglobinA," level
of 6.5%o.She was subsequentlyprescribedbasal bolus insulin and has remained on this form of
therapy with modest dosagechangesover the years. She has never been hospitalizedfor severe
hyperglycemia. She has never experienceda severehypoglycemic reaction requiring assistance,
although she did have frequent symptomatic hypoglycemia at one point that required reduction
in her insulin dosage.She has no complications of diabetes.She walks 4 days weekly, and her
weight has been stable other than pregnancy-relatedweight change.The patient has a history of
gestationaldiabetesmellitus in 2 pregnanciesoccurring at age35 years and 39 years; shewas
treatedwith insulin in both instances.
In reviewing her family history you learn that her father was diagnosedwith
Wpe2 diabetes
mellitus late in life, her mother died of complications of alcoholism at age58 years and was
not known to have diabetes,her brother has hypothyroidism, and a normal-weight cousin has
insulin-treated diabetesalthough few details are known to the patient.
Her current medications include insulin glargine, 13 units each morning, and insulin aspart,
I unit per 15 g carbohydrateand 1 unit per 50 mg/dl correction over 150 mg/dl (but she never
requires correction insulin).
Blood pressureis 121163mm Hg, and pulse rate is 73 beats/min. She is 62 inches tall and
weighs 124 pounds (BMI : 22.7 kglm2). Findings from neurologic and physical examinations
are normal, including a normal-sized thyroid gland without nodules. She has no vitiligo or other
skin abnormalities.
Recent laboratory test results:

Potassium:3.8 mEq/L
HemoglobinA," : 5.80lo
Albumin to creatinine ratio: 4 pglmg
LDL cholesterol : 86 mgldL
Laboratory test results from the time of diagnosis:

Hemoglobin Ar":6.5%o
C-peptide : 0.8 nglml. (when glucose was 112 mgldl,)
Thyroperoxidaseantibodies: 1.4 IIJ lmL
Thyroglobulin antibodies : 79.7 IU/nL
TSH: 1.1mIU/L
Glutamic acid decarboxylaseantibodies,negative
Islet cell antibodies,negative
In responseto thepatient's question of whether she still needsinsulin therapy, which one of the
following is the bestplan?
A' Prescribeglimepiride,2 mg daily, considering the possibility of type 2 diabetesmellitus
B. Order a CT scanto evaluatefor potential occult pancreaticcancer
C. Reassureher there is no doubt about the diagnosis
D. Order molecular genetic testing looking for a potential glucokinasegene mutation
E. Assay for glutamic acid decarboxylaseantibodiesagain
26 ESAP20t0*QUE$TIONS )
/
26
Question
[24-year-old woman is referred from the dermatology clinic for evaluation and management
of hypertriglyceridemia and diabetesmellitus. She sought the care of a dermatologistbecauseof
recurrent eruptions on her arms and legs that have developedin the last 2 years.
The patient reports that she had been diagnosedwith hyperlipidemia and diabetesat age
20 years. She had been treated for a short period with insulin, but discontinuedthis in the past
year.Shehas had no recentor past history ofsevere abdominalpain or pancreatitis,has not been
hospitalized,and hasnot noted changesin body weight. Shereportsthat shehas alwaysbeenthin
and muscular. She does not smoke cigarettesor drink alcohol. Her father died at age52 years of
a myocardialinfarction, and shehas a sisterwho also has diabetesmellitus and a tipid disorder.
Shehad onsetof mensesat age 12 years,but has always had irregularperiodsthat have become
more infrequent in the past2 years. Medications include metformin, glipizide, and gemfibrozil.
On physical examination,the patientis 66 inchestall and weighs 116pounds(BMI : 18.7
kglm2). Blood pressureis 109/70 mm Hg. There is no goiter, and findings from cardiovascular
examination are unremarkable.She is lean and appearsfit with no dysmorphic features.There
is acanthosisof the neck and axillae and coarseterminal hairs on the chin and linea alba. Her
abdomenis soft with the liver edge palpable under the right costal margin. There is a notable
paucity of subcutaneousfat on her trunk, neck, and upper and lower extremities, with prominent
veins and musculature.Palms and solesappearnormal. There are cropsof raisedyellow and pink
papuleson her upper back, buttocks,and dorsumofher thighs.
Laboratorytest resultsfrom a blood samplecollectedwhile fasting:

Glucose:232 mgldL
T S H : 1 . 3m l U / L
Aspartateaminotransferase : 65 UIL
:
Alanine aminotransferase 73 UIL
Which one of thefollowing would be the single most effective treatmentfor this patient?
A. Adiponectin
B. Pioglitazone
C. Exenatide
D. Leptin
E. Niacin
27
Question
A 36-year-old man develops suddenonset of severeright flank pain radiating into the right
scrotum.He also notesbright red blood in his urine.
On physical examination, temperatureis 98.5'F, and there is tendernessto palpation over the
right flank that extendsinto the right lower abdomen.No abdominal massesare palpable, and
findings from the scrotal examination are normal. Plain x-ray of the abdomendoes not show any
InASSES.
ffi$Ap
*s1s**L,trsYtsru$27
Hemoglobin :12.7 gldL
White blood cell count: 8900/PL
Albumin:4.0 gldL
Bicarbonate:25 rlnEqlL
Calcium: 10 mg/dl
Chloride : 102 mBqlL
Creatinine:1.4 mgldL
Phosphorus :3.6 mgldL
Potassium:4.3 mEqlL
Sodium:142mF,q1L
Urinary calcium : 173 mgl24 h
Urinary creatinine : 2 gl24 h
Urinary citrate: 510 mgl24h
Urinary oxalate : 28 mgl24 h
Urinalysis:
Uric acid crystals are seenunder high-power magnification
4+ red blood cells (greaterthan 100 red blood cells per high-powerfield)
Albumin, negative
Glucose,negative
pH: 5.1
The patient is admitted to hospital becauseof increasedflank and abdominal pain and the
persistenthematuria.An intravenouspyelogram reveals a lucent mass located in the middle
one-third of the obstructedright ureter.A urologic procedureremovesthe obstruction, and
normal urine flow is reestablished.Additional history reveals increasedfood intake and gastritis
symptoms controlled by an H, antagonist.

Serumcreatinine: 1.1 mg/dl
Serumuric acid : 5.4 mgldL
Urine volume: 1.3L
UrinepH: 5.0
Urinary uric acid :830 mgl24h
Urinary sodium:155 mB(24h
A secondintravenouspyelogram shows no filling defect after contrast medium is given.
Which one of thefollowing is the most likely diagnosis?

A. Hyperuricosuria
B. Mixed calcium oxalate and urate stone
C. Chronic urinary tract infection
D. Gout
E. Renaltubular acidosis
/
28
Question
A 68-year-old man with an 1S-yearhistory of type 2 diabetesmellitus is referred to you- He has

long-standing diabetic neuropathy and has had an ulcer over the fifth metatarsalhead at the site
of a former callus for 1 month. Becausethe ulcer is painless,he has not sought medical attention.
28 &$&p*s'fi&*&umsfi*N$
During the past week, there has been increaseddrainage from the ulcer and erythema around the
ulcersite.
On physical examination,the l-cm ulcer appearsto be moderatelydeep.There is a moderate
amountof foul-smellingdrainage.The dorsalispedis and posteriortibial pulsesare 2+. His
temperatureis 99.5'F.
Erythrocyte sedimentationrate: 40 mmlh
HemoglobinAr":9.7Yo
White blood cell count: 12,00011tL
Blood glucose:250 mgldL
Plainx-rays of his foot show possiblethinning of cortical bone with loss of trabeculae.You
suspectthat this patient has osteomyelitis, and you order blood cultures before prescribing any
antibiotics.
Whichone of thefollowing testswould best establish the diagnosis of osteomyetitis?

A. Gadolinium-enhancedMRl
B. CT scan
C. Triple-phasebone scan
D. Wound culture
E. Indium 111white blood cell scan
Question29
A 50-year-oldwoman presentsto her primary care physician with mild symptoms suggestive
of hyperthyroidism, which include anxiety, increasedsweating, irritability, and an inability to
concentrate.Her menseshave been very irregular and sparseover the past year. Her medical
history is unremarkable.The patient has not been taking estrogenreplacementtherapy.
Physicalexaminationrevealsa somewhatanxious-appearing woman. Sheweighs 120pounds
(BMI : 22kglm2), pulse rate is 96 beats/min,and blood pressureis 130/60mm Hg. Shehas a
mild tremor of her outstretchedfingers.The thyroid gland is easilypalpable.
Her primary care physician suspectshyperthyroidism and orders the following thyroid
functiontests:
Serumtotal T,r:20 pgldL
Serumtotal T, :200 ngldL
SerumTSH:2mIUlL
In view of the markedly elevatedTo and T, concentrations,the patient is referred for endocrine
evaluation.
The family history you obtain includes radioactive iodine-treated hyperthyroidism in the
patient's father, goiter in a paternal aunt, and a 5-year-old grandsonwith attention deficit disorder.
The concentrationof serumfree To by equilibrium dialysis is mid-rangeof normal. The free T.
conce\ation is also normal.

A. TSH-secretingpituitary tumor
B. Thyroid hormoneresistance
C. Hyperthyroidism
D. Thyrotoxicosisfactitia
E. Familial dysalbuminemic hyperthyroxinemia
ffi$&p*{}"!{}*&t*ffi$Tt*$$#
29
Question
30
*,i,l,;;**;vff:1,,:',:..:,T'ijy*:|ln :ru let {1e3r cyst.rheparient

hadpresented
]'[],'#ijliT"f ;il:'T:'fifi:H1ilTff;
HH',:'ll,:l:1:Ti1T;"r"*'r'"'ffi
+i:i;;;1iff il::JHii"#tyff
:""',:
:iff**:?':::i::nr"it.Fffi;;ffi
rhepatienthasnohis:::@ilffi ;ffffi *i":Hfi#J".$,T_,*nil::::il:",
Cushing syndrome,pheochroir-o.Vtornu,
or hyperaldosteronism.Her medications
are acetaminophenwith codeine
and
conjugatedestrogens.
On physical examination, BMI is
29.3kg1m2, bloodpressureis 140/75mm
Hg, and heart rate is g2 beats/min.
The
patient appearswell. Findings
from the
abdominal and lymph node examinations
are normal. Findings from the remainder
of the physical examination are
unremarkablewith the exception
of
neurologic findings related to her
left_
Abdominal MRI showinga 6_cmleft sided radiculopathy.
adrenalcyst.
thebestnextstepin themanagement
of thisadrenatcyst?
T,
A. !"::3::!::yr.^
Perform left adrenalectomv
B. Performfine-needleaspirationbiopsy
anddrainageof the cyst
C. grformovernightdexamethason.
f rupp..rsion test
D. Measure24-hoururinefractionatea
rie'tanf hrinesandcatecholamines
E. Follow up with anotheradrenalMRI
in: io Omonths
Question
31
427-year-oldwomanvisits your office
for consultationandmanagement ofpossiblethyroid
disease'Thepatientwas initially
tr", ourt"t i"ffiynecologist for infertility
aftera 4-yearhistoryof apptop.iut"ry
"rruluatedby
ii-ed, unprotecteainterc'ou.se. Initial workup
revealedunexplainedinfertility with
documented ovulatorycyctesandnormalfindings
hysterosalpingogram.Her husLanafruJu no..al semenanalysis. from
Laboratorytestresultsfrom her initial

evaluation:
FSH: 7.7lU/L
Estradiol:42 pglmL
TS\ 4.9 mIrJtL
Prolactin: 15nglml,
Thepatienthashad6 unsttccessful
cyclesof clomiphenecitratetreatment
obstetrician/gynecologist' underthe careof her
Before.o"*iiurion for in vitro rertiti
to her internistandreceivedu pt.t".ifri* )ation,the patientwasreferred
for levothyro*in"i"L.e of a ,,thyroid
Thepatientis now seekinga second abnormality.,,
becausesher.ri.ila her own records
normalTSH value' Shedoesnot wantio "pirr* andsawa
takeanymedicationsthat couldpotentially
sinceshehasbeentryingto getpregn""; harma baby
;; so manyyears.
c$Ap2sr0*QUESTtoNs
You confirm that her medical history is unremarkable.She has no surgical history. She
reportsnormal development,with menarcheat age 13 years and consistently regular cycles.
Shestatesthat she does not use tobacco, alcohol, or drugs and avoids caffeine. She is taking a
prenatalvitamin with folate daily. She has a family history of unknown thyroid diseasein her
mother,which has been treatedwith medication since her mother was in her 40s. Her brother has
type 1 diabetesmellitus. Physical examination findings are unremarkable.The thyroid size is at
the upper limit of normal, the gland is symmetric, and a nodule is not appreciated.
Her TSH concentrationis now 3.7 nIIJIL and thyroperoxidaseantibodies are present-
Wich one of thefollowing should be the next step in thepatient b care?

A. Start levothyroxine before initiating any fertility ffeatments
B. Start levothyroxine once pregnancy has been confirmed by ultrasonography
C. MeasureTSH again after she has a positive pregnancytest and treat accordingly
D. No funher treatment
E. Confirm thyroid statuswith free To before making further managementdecisions
32
Question
A comatose75-year-old man is brought to the emergencydepartmentfrom a nursing home. He

had been doing well until a fall several days ago when he hit his head on the floor causing a scalp
laceration,but no loss of consciousness. Sincethen, he has becomeintermittentlyincontinent
of urine, and the nursing home staff has limited his accessto water to try to reduce the episodes
of incontinence.Over the past few days, he has become increasingly lethargic. Medical history
includeshypertension and coronary artery disease.
Findings from the physical examination include severedehydration, dry mucus membranes,
andtentingof the skin. Blood pressureis 85/55 mm Hg;pulse rate is 115beats/min;and weight
is 154pounds(70 kg).
Serumcreatinine:2.0 mgldL
Serumglucose: 100 mg/dl
Plasmaosmolality : 360 mOsm/kg
Serumpotassium: 5.0 mEq/L
Serumsodium:175 mEq1L
Serumurea nitrogen:50 mg/dl
Urine osmolality : 300 mOsm/kg
Urinary sodium: <5 mEq/L
Wich one of thefollowing would be the most appropriate therapy?

A. Infuse 7 L of dextrose 5oloin water (D5W) over 24 hours
B. Infuse 2L of o.9%NaCl over 24 hours, then2 L of D5W over the next24 to 48 hours
C. Administer desmopressin,2 mcg subcutaneously,then infuse D5W at 100 mllh until the
plasma sodium concentrationis normal
D. Administer desmopressin,2 mcg subcutaneously,then infuse 0.9% NaCl until blood pressure
and pulse rate arestable and urine output is established,then D5W for a total infusion
volume of 3.5 L over24 hours and then another3.5 L over the next24 to 48 hours
E. Administer desmopressin, 2 rycg subcutaneously,then infuse 3.5 L of D5W over 24 hours,
then another 3.5 L over the next24 to 48 hours
fsls*QUffi$nOru$ 31
HS&p
33
Question
to have gestational
A 3O-year-oldobesewoman, now in het 2gthweek of pregnancy'was found
her diet
diabetesmellitus 4 weeks ago. She was counseledby a dietitian and has followed
in the first 2 weeks after diet therapy was initiated'
prescription carefully. she gained no weight
to 30 minutes daily. Fasting
She has increasedher walking from 15 minutes 3 times weekly
in a local
and 2-hour postprandial (aftei breakfast) plasma glucose concentrations,measured
measured
laboratory,were 95 and 115 mgldL,respectively. Capillary blood glucose values
and dinner averaged 88 and 110 mg/dl,
before breakfast and dinner urrd2 ho.nr after breakfast
4 of the last 6 days' and
respectively.Urine ketoneswere moderately positive before breakfast on
to her bedtime
trace or small before dinner. She has been advised to add 20 g of carbohydrate
snack.
trace, and
Now, 4 weeks after the diagnosis,her urinary ketoneshave been negative or
her weight gain has averaged0.4 poundsper week. capillary blood glucoseconcentrations
to increase,
have been somewhatvariable and the preprandial and postprandialvalues tended
past week' Fasting and 2-hour
with averagesreaching 96 and 120 mgldL,respectively, in the
postbreakfastplasma glu"or" concentrationsare I02 and 130 mg/dl, respectively'
Wich one of thefollowing is the most appropriate therapeutic recommendation?

A. Continue her PresenttheraPY
B. Begin insulin
C. Add 200 caloriesdailY
D. Increasewalking time to 60 minutes daily
E. Measureblood glucose7 times daily
34
Question
of
A 35-year-old woman is referred to you for advice about a serum calcium concentration
had a duodenal ulcer treated
12 mgldL. She has not had kidney stonesor bone fractures. She
since she
successfullywith omepr azole I yeat ago,although she reports intermittent heartburn
mg daily' for
stoppedthis medication9 monthsago. Shehas beentaking bromocriptine,2'5
that presented with menstrual
the past 3 years to treat a prolactin-producing microadenoma
to treat
irregularity. She has taken no other medications.Her mother had apatathyroidectomy
the patient's
hypercalcemiayears ago and now has recurrent hypercalcemia.Findings from
physical examination are normal.

Gastrin:400 PglmL
PTH: 105pg/ml
Prolactin: 10 nglml-
Calcium: 11.9mg/dl
Urinary calcium :280 mgl24h
Urinary creatinine:0.9 gl24h
a parathyroid
Bone densitiesof the spine and forearm are normal. You refer the patient to
says that he has identified 4 parathyroid
surgeon.He calls yo., fro- the operating room and
the enlarged gland'
gtands.One is enlargedand 3 appearnormal. He has already removed
32 ilssB}*#'!*^**#ffis?i*Ns
Wich one of thefollowing coursesof action do you suggestto him?
Remove 2 and one-half of the other parathyroid glands
Remove the remaining 3 parathyroid glands
Perform a biopsy of I of the remaining parathyroid glands and await
the report
Remove no further parathyroid tissue
Perform a biopsy of the thyroid gland
Question
35
A 75-year-oldwoman has a2- to 3-year history of a very large goiter.

Except for her appreciation
of the increasingsize of the irregularly shapedthyroid giuno, ttt-"patient
rrasnaa no symptoms of
thyroid dysfunction. she has no local symptoms of airway obstruition.
Except for a jort-lived
episodeof atrial fibrillation many years ago, the patient has an
unremarkablemedical history.
Examinationrevealsan obesewoman (BMI: 32kg/m2)who ambulates
slowly with
the help of a cane.Vital signs are normal. She has no endocrine
ophthalmopathy.iervical
lymphadenopathyis absent.An asymmetric thyroid gland that is
5 times normal size is
easily seenand readily palpated. Several large nodules are felt in
the right thyroid lobe. The
gland moves well with swallowing, and there are no thyroidal
bruits. rung netOsare clear to
auscultation,and the catdiac examination flndings are normal. There
is no substernaldullness to
percussion'There is no tremor of the outstretchedfingers,
and deep tendon reflexes are normal.
Serumthyroglobulin: 530 nglmL
SerumTSH: 3.7 nIIJIL
Serumthyroid antibody titer panel, negative
Findings from fine-needleaspiration biopsy are nondiagnostic.

Finding from thyroid core-needle
biopsy of 2 nodules larger than 2 cm indiameter show Htirthle cell (oxyphilic
clll; carcinoma.
Foci ofvascular invasionare noted.
Chestx-ray is unremarkableand shows no substernalextension
of the thyroid gland and no
pulmonarynodules.
Wich one of thefollowing is thepreferred managementstrategy?

A. Radioablationof the thyroid gland
B. Total thyroidectomy with ipsilateral (right) central neck lymph
node removal
C' Total thyroidectomy with right central neck lymph node iernoval;
postoperativesuppression
of endogenousTSH with thyroid hormone
D' Total thyroidectomy with right central neck lymph node removal,
postoperativeradioablation
of residual thyroid tissue, and postoperativesuppressionof endogenous
TSH with thyroid
hormone
E. Referral to oncology for chemotherapy
Question
36
444-year-old woman presentsto the emergencydepartmentwith

a3-dayhistory of nausea,
vomiting,and abdominalpain. Her medicalhistoryis notablefor
bilateral adrenalectomy
3 months ago to treat cushing syndrome,type 2 diabetesmellitus,
hypertension,and
hyperlipidemia.Her medicationsinclude hydrocortisone,20mg
eachmorning and l0 mg each
evening;glyburide, l0 mg daily; gemfibrozil.600 mg twice daiiy;
and benazepril,40mg daily.
tr$Ap?s.,$*QLJn$flSt{$33
Blood pressureis 123176mm Hg, and pulserate is 104 beats/min.She is not in acute
distress.The abdomenis soft, but shehas moderateepigastrictenderness.Bowel soundsare
hypoactive; there is no guarding or rebound. The stool is negative for gross or occult blood. She
has scatteredwhite papuleswith an erythematousbaseover her shoulders,back, and buttocks.
Blood and urine sampleshave been sent to the laboratory and the results are pending. A
capillary blood glucosemeasurementis 210 mgldL. A lipid panel obtainedin the clinic 1 day
before presentationshowed a serum triglyceride concentrationof 24,000 mgldL and a total
cholesterolconcentrationof 2250 mgldL.
An emergencydepartmentphysician asks you for an opinion regarding the managementof
her extremelyelevatedlipid levels.
In addition to prohibiting oralfluids andfood, which one of thefollowing should you do?
A. Add niacin
B. Add atorvastatin
C. Administer heparin intravenously
D. Start intravenousglucose and insulin
E. Decreasethe hydrocortisonedosageby 50%
37
Question
A27-year-old man consults you regarding strategiesto preservereproductive function. He was

recently diagnosedwith systemic lupus erythematosusand nephritis, and his rheumatologist
intends to prescribe cyclophosphamideat a dosageof 150 mg daily for 6 months. In their
discussions,his physician has made it clear that there is a high incidence of permanentgonadal
dysfunction subsequentto this treatment.The rheumatologist suggestedspern cryopreservation,
but also suggesteda visit with you for a secondopinion.
The patient has a girlfriend who usesoral contraceptives.They have never considered
having children and he has not fathered a child in the past. One week ago, he had a full semen
analysis that was entirely normal. He has no history of any endocrine disorder.
On physical examination,blood pressureis 142178mm Hg and pulserate is 86 beats/min.
He is 67 inchestall and weighs 154 pounds(70 kg) (BMI : 24.1kglm2).Findings from his
examination are unremarkableas they relate to reproductive function. He has normal male
secondarysexual characteristics.On genitourinary examination, he has a normal phallus and
testes.
You explain that although the data are limited, an option has been shown to afford gonadal
protection in this setting. Becauseany approachmay have some rate of failure, sperrnbanking is
planned.
In addition, which one of thefollowing hormonal treatmentswould you advocatefor gonadal

protection?
A. DHEA
B. Testosterone
C. Dexamethasone
D. Medroxyprogesteroneacetate
E. Estradiol
i
34 #*$&tr*i!'t**#ti #$T***i{S
Question38
464-year-old woman is admitted to the hospital for a coronary artery bypassprocedureto treat
progressive,uncontrolled angina and dyspneaon exertion with minimal activity. She has a 12-
year history of type 2 diabetesmellitus.
Medicationsinclude metformin, 1000mg twice daily; glimepiride,4 mg daily; NpH
insulin,3T units at bedtime;atorvastatin,80 mg daily; lisinopril,20 mg twice daily; long-acting
metoprolol,100 mg daily; and omeprazole,20mg daily.
Recentlaboratorytest results:
Creatinine: 1.0 mgldl-
Potassium:4.5 mBqlL
TSH:2.1nIUIL
LDL cholesterol: 73 mgldL
HemoglobinAr.:7 .8o/o
Wth regard to her glycemic control, which one of thefollowing is most appropriate immediately
after the operation?
A. Basal insulin in combination with metformin and supplementaryrapid-acting insulin
analogueby hospitalprotocol scale,with glucosegoal of lessthan 150 mgldL
B. Insulin glargineat a dosageof 0.l5 U/kg per day and insulin aspartat a dosageof 0.15 U/kg
per day in 3 divided doses,with glucosegoal of lessthan 140 mgldL
C. Intravenousinsulin infusion accordingto standardizedprotocol,with glucosegoal of 80 to
ll0 mgldl
D. Insulin glargineplus supplementaryinsulin aspartby scale,with glucosegoal of lessthan
250mgldL
E. Intravenousinsulin infusion accordingto standardizedprotocol,with glucosegoal of 140 to
180mgldl.
39
Question
A 32-year-oldman has recently discovered2 lumps in his right anterior neck that appearto be
increasingin size.His father is said to have died of thyroid cancerat age36 years.The patient's3
youngersiblingsare in good health.He is single and doesnot have any children.
He doesnot appearill. Pulserate is T2beatslmin,and blood pressureis 170/105mm Hg.
Thereare 2 firm nodules in the right lobe of the thyroid gland-l in the upper part and I near the
midline,eachabout2 cm in diameter.The left lobe is barely palpable.Multiple small anterior
cervicalnodes are present in ihe right neck.
Completeblood cell count and routine blood chemistries,normal
SerumTSH: 1.5mIU/L
Serumfree To : 1.6 ngldL
Thyroid antimicrosomal antibody, negative
Serumcalcitonin:29,000 pglmL
Urinary total metanephrines: 1840 1tgl24h
Thyroid scanshows 2 cold regions in the right lobe correspondingto the palpable nodules.
H$&p**'ns**{Jtr$?t*$d$ 35
Wich one of thefollowing would be the best test to determine whether his 3 siblings qre ot risk
for his disease?
A. Measurebasalserumcalcitonin in his siblings
B. Measure urinary fractionated metanephrinesin his siblings
C. Perform DNA analysis for a REZproto-oncogene mutation in the patient
D. Perform thyroid ultrasonographyin his siblings
E. Perform thyroid radioiodinescanin his siblings
40
Question
A 64-year-old woman is referred for evaluation of

hypertensionand hypokalemia.Shehas a7-year
history ofhypertensionand recentpoor control.
Over the last 6 months,shehas had blood pressure
readingsas high as 190/110mm Hg and 2301106mm
Hg. She has no family history of hypertension.Her
medicationsinclude amlodipine,10 mg once daily;
losartan,100 mg once daily; and metoprolol, 100 mg
once daily. The patient is keen to consider a surgical
approachto either cure or improve her hypertension.
On physical examination, she is symmetrically
obese(BMI :33.6k91m2). Blood pressureis 170184
mm Hg (right arm) and 172194mm Hg (left arm),
and heart rate is 64 beats/min. She appearswell.
The heart soundsand findings from abdominal AbdominalCT showsa3.3 x 2.l-cmhypodense
examination are normal. (<5 Hounsfieldunits) nodule (arrow) inthe
medial aspectofthe left adrenalgland and a
normal-appearingright adrenalgland.
Sodium:143 mE{L
Potassium:3.4mB(L
Plasmaaldosteroneconcentration: 17 ngldL
Plasmarenin activity: <0.6 nglml- per hour
Urinary aldosteroneexcretionon a high-sodiumdiet : 161tgl24h (urinary sodium:323
mBql24h)
Which one of thefollowing should be done next?

A. Adrenal MRI
B. Posturestimulationtest
C. Adrenal venoussampling
D. Serum 18-hydroxycorticosteronemeasurement
E. Laparoscopicleft adrenal-ectomy
41
Question
A24-year-oldwoman is hospitalizedlate in the 37 and Sl7thweekof her first pregnancywith

symptoms of dysarthria and confusion. She has been observedclosely the preceding 2 weeks
becauseof preeclampsia.
36 ffi$&p3$'r**&u*$Yt*ht$
Laboratorytest results (drawn at 7 AM):
Sodium:129 nEilL
Hemoglobin:9.8 gldL
MCV:98 pm3
White blood cell count:5600/pL
Platelets=45xI03l1tL
Fibrinogen: 110 mg/dl (referencerange, 200-375 mg/dl.)
Prothrombintime : 16 s (INR: 1.6)
Alkaline phosphatase :205 UIL
Alanine aminotransferase: 75 UIL
Fastingblood glucose:52 mgldL
An endocrineopinion is sought before an emergencycesareandelivery is performed in the next

30 minutes.Blood pressureis currently ll5l90 mm Hg, and heart rate is 115 beats/min. She is
asymptomatic.However, on examination, she has marked hyperreflexia and difficulty subtracting
serial7s from 100.Her cognition improves aftera 50-mL bolus of 100/o dextrose(D10)
In addition to recommendingiffision of DI0 at 100 mL/h, how should you advise the
obstetrician?
A. MeasureB-cell polypeptides from the initial venous sample
B. Obtain a sulfonylurea screenfrom the initial venous sample
C. Give 100 mg of hydrocortisone intravenously after measuringACTH and cortisol
D. Screenfor antiphospholipid antibodies after ensuring that the patient has not received
heparin
E. Requestan MRI of the brain
42
Question
An 8O-year-oldwoman is referred to you becauseof vertebral fractures andpuzzling laboratory

findings.Shehad been in good health until2 weeks ago when she developedacute back pain.
Spinalradiography showed a vertebral fracture. She reports that 30 years ago, she was told her
blood calcium level was slightly high and that she had an overactive parathyroid gland. Her
physician atthat time said it would probably never causea problem. She underwent menopause
atage 52 years and has never taken estrogen.She recalls no other bone pain and has never had a
kidney stone.
Laboratorytest results from I week ago:

PTH:250 pglmL
Calcium:9.2 mgldL
Serumureanitrogen: 15 mg dL
Whichone of thefollowing is the most reasonablenext step?

A. Measurethe serum concentrationof l,25-dihydroxyvitamin D,
B. Prescribeanalgesicsandprovide reassurance
C. Prescribevitamin D and measureher serum calcium concentrationfrequently
D. Urge her to consider taking estrogen
E. Infuse PTH in an attempt to diagnosepseudohypoparathyroidism
E$AP2010-QUTSTION$37
43
Question
424-yeat-old woman is referred by her obstetrician for evaluation of severethirst and urinary
frequency that developed severalmonths after she becamepregnant for the first time. Two years
before, she had been treated with a dopamine agonist for a prolactin-secretingmacroadenoma.
She reports no other abnormal symptoms including headaches,visual disturbances,excessive
weight gain, or edema.Her obstetrician determinedthat she does not have hyperglycemia or
glucosuria and reports that her pregnancy appearsto be normal otherwise. Her family hiistoryis
noncontributory.
Findings from her physical examination are unremarkableexcept for signs consistentwith a
pregnancy at 6 months'gestation.

Plasmaosmolality : 285 mOsmlkg
Basal plasma sodium : I40 mEq/L
Urinary osmolality: 190 mOsmlkg
Urine specific gravity : 1.007
Urine volume:9.5 L/24h
During a fluid deprivation test, her plasma sodium level, plasma osmolality, and urinary
osmolality rose to I43 n:f,ilL,290 mosmlkg, and 225 mosmkg, respectively.However,
her thirst increasedso markedly that she was given an injection of desmopressin,2 mcg
subcutaneously,and allowed to resume drinking. Two hours later her urine osmolality had
increasedto 375 mOsmlkg.
MRI of the brain was unremarkableexcept for slight asymmetric enlargementof the anterior
pituitary gland and nonvisualization of the posterior pituitary bright spot.
Wich one of thefollowing options would be the best next step?

A. Start therapy with desmopressin
B. Treat with a vasopressinreceptor inhibitor
c. Measure plasma arginine vasopressinduring a fluid deprivation test
D. Measureplasma arginine vasopressinafter the infusion of 3Yosaline when the plasma
osmolality reaches300 mOsmlkg
E. Tell the patient that her thirst and polyuria will remit after delivery
44
Question
A 65-year-old man statesthat he has been experiencing dizziness,weakness,antl irritability.

He finished treatment for bladder cancerwith M-VAC (methotrexate,vinblastine, doxorubicin,
and cisplatin) 2 months ago. He takes a B-adrenergicantagonist and athiazide to control high
blood pressure.Cystoscopicmonitoring revealsregressionof gross tumor. Findings from his
examination include severalbeatsof nystagmusto right and left laterul gaze and,presenceof the
Chvosteksign.
Laboratory serum test results:

25-Hydroxyvitamin D : 20 nfl mL
Bicarbonate:30 mEq/L
Calcium:7.6 mgldL
Chloride: 101 mEq/L
38 E$Ap?01CI-eL'*$Tt0Ns
43
Question
424-yeat-old woman is referred by her obstetrician for evaluation of severethirst and urinary
frequency that developedseveralmonths after she becamepregnant for the first time. Two years
before, she had been heated with a dopamine agonist for a prolactin-secretingmacroadenoma.
She reports no other abnormal symptoms including headaches,visual disturbances,excessive
weight gain, or edema.Her obstetrician determinedthat she doesnot have hyperglycemia or
glucosuria and reports that her pregnancy appearsto be normal otherwise. rtei amitv historv is
noncontributory.
Findings from her physical examination are unremarkableexcept for signs consistentwith a
pregnancyat 6 months'gestation.

Plasmaosmolality : 285 mOsmlkg
Basal plasma sodium : 140 mEqlL
Urinary osmolality: 190 mOsmlkg
Urine specificgravity : 1.007
Urine volume:9.5 Ll24h
During a fluid deprivation test, her plasma sodium level, plasma osmolality, and urinary
osmolality rose to 143 rnBdL,290 mOsmlkg, and 225 mOsmkg, respectively.However,
her thirst increasedso markedly that she was given an injection of desmoprer.in, 2 -"g
subcutaneously,and allowed to resume drinking. Two hours later her urini osmolality had
increasedto 375 mOsmlkg.
MRI of the brain was unremarkableexcept for slight asymmetric enlargementof the anterior
pituitary gland and nonvisualization of the posterior pituitary bright spot.
Wich one of thefollowing options would be the best next step?

A. Start therapy with desmopressin
B. Treat with a vasopressinreceptor inhibitor
c. Measureplasma arginine vasopressinduring a fluid deprivation test
D. Measureplasma arginine vasopressinafter the infusion of 3Yosaline when the plasma
osmolality reaches300 mOsm&g
E. Tell the patient that her thirst and polyuria will remit after delivery
44
Question
A 65-year-old man statesthat he has been experiencing dizziness,weakness,antl irritability.

He finished treatment for bladder cancerwith M-VAC (methotrexate,vinblastine, doxorubicin,
and cisplatin) 2 months ago. He takes a B-adrenergicantagonist and athiazide to control high
blood pressure.Cystoscopicmonitoring reveals regressionof grosstumor. Findings from his
examination include severalbeatsof nystagmusto right and left lateral gaze andpresenceof the
Chvostek sign.

Calcium:7.6 mgldL
Chloride: 101mEq/L
ESAp
3S10-nUf;$TtON$
Magnesium:0.2 mgldL
Potassium:3.0 mEq/L
Sodium: 138 mEq/L
Serumurea nitrogen:22 mgldL
In addition to giving intravenous calcium and discontinuing thiazide,you should administer

which one of thefollowing?
A. Oral potassiumchloride
B. Intramuscularmagnesium sulfate
C. Supplementwith vitamin D
D. Oral magnesiumchloride
E. Inhavenousmagnesium sulfate or chloride
Question45
You are askedto examine a 40-year-old woman with a history of polycystic ovary syndrome
who recently completed ovulation induction and intrauterine insemination. She is now in early
pregnancyand presentswith right lower-quadrantabdominal pain and hypotension.
Shehas long carried the diagnosis of polycystic ovary syndrome and has been taking
metformin for 5 years. She and her husbandwere unable to conceive for 3 years and were fully
evaluatedfor infertility. No etiology other than polycystic ovary syndromewas identified, and
sherecentlyunderwent ovulation induction. On day 5 of her last cycle, she startedexogenous
gonadotropins(recombinant human FSH). She did not meet criteria for diabetesmellitus, but
shedid have insulin resistancebefore ovulation induction. On day 14, ovaianultrasonography
showedmultiple small follicles bilaterally. By day 22,repeatedultrasonographyshowed 2
developingfollicles on the right side, 1l x 11 mm and 10 x 1l mm. On day27, her estradiol
concentrationwas 1760 pg/ml-, and on day 28, she received hCG after ultrasonographyrevealed
2 righfsided follicles, 23 x 23 mm and 24 x 26 mm. The subsequentday, she had intrauterine
insemination,and on day 44, conception was confirmed with a positive pregnancy test.
One day after the positive pregnancy test result, she came to the emergencydepartmentat
your hospital with right lower-quadrantabdominal pain. The pain is sharp and intermittent. She
notesa 7-pound weight gain, mostly in the past week. She has no nausea,emesis,fever, chills, or
vaginalbleeding. There is no shoulder or chest pain.
On examination, she is afebrile. Blood pressureis 108/64 mm Hg, and heart rate is 88 beats/
min. Findings from cardiac and pulmonary examinationsare normal. On abdominal examination,
shehasnormal bowel soundswith right lower-quadranttendernessbut without rebound. She has
no evidenceof periumbilical ecchymosis(Cullen's sign). Genitourinary examination also reveals
markedright-sided tenderness.You cannot determine if there a massbecauseof the discomfort.
Thereis no evidenceof uterine bleeding.
Electrolytes,normal
Liver enzymes,normal
Hematocrit:48%
Urinalysis,normal
39
E$AP201O-QUESTIONS
\
Which one of thefollowing is the most appropriate next step?

A. Pregnancytermination
B. Pelvicultrasonography
il C. Laparoscopy
l D. Serumestradiolmeasurement
E. Hysterosalpingogram
46
Question
A48-year-oldmanpresentsfor evaluationandmanagement of dyslipidemia.He is in general

goodhealth,andhis only regularmedicationis anACE inhibitor for hypertension. Coronary
heartdiseasedevelopedin his brotherat age44 yearsandin his fatherat age54 years.His father
alsohasApe 2 diabetesmellitus.
Thepatientweighs185poundsandis 68 inchestall (BMI : 28.1kg/nr3).Waist
circumference is 104cm. Blood pressureis 140/85mm Hg, andpulserateis 82 beats/min.There
areno xanthomas.
You recommendlifestylechangesandreferhim to a dietician.While following anAmerican
HeartAssociationTherapeuticLifestyleChangescalorie-restricted diet (formallyknown asthe
StepII diet) for 3 months,he loses5 pounds.
Follow-uplaboratorytestresults:
LDL cholesterol: 146mg/dL
Totalcholesterol: 257 mgldL
Triglycerides: 495 mg/dL
TSH : 2.0 imlulL
Creatinine:0.9mg/dl
Fastingplasmaglucose: 118mgldl
Serumureanitrogen: l5 mgldL
Wich oneof thefollowingmedicationswouldyou now add to his regimen?

A. Nicotinic acid
B. Fenofibrate
C. Clofibrate
D. Metformin
E. Cholestyramine
47
Question
A 58-year-oldwomanis scheduledfor an electivecholecystectomy. In additionto gallbladder

disease,her medicalproblemsincludeobesity(34.2k9/nl), gastroesophageal reflux,and
hypertension.Medicationsincludeenalapril,5 mg daily; calcium,500mg twice daily;vitamin
D,200IU twice daily; and pantoprazole,40
mg daily.
Fastinglaboratorytestresultsfrom preoperativeevaluation:
Creatinine:0.9mg/dl
Potassium:4.3mE{L
Glucose: 109mg/dl
Sodium: I42 mBqlL
40 rsAP2010-QUFSTTONS
HDL cholesterol: 4l mgldL
Hematocrit: 413%
Wich one of thefollowing is the most appropriate responseto the elevatedglucose level?
A. Measurefasting glucose 6 weeks after the operation
B. Tell her shehas prediabetesand that she should begin a low-fat, reduced-caloriediet and an
exerciseregimen after she recovers from the operation
C. MeasurehemoglobinA,"
D. Begin metformin, 500 mg twice daily, and increaseto 1000 mg twice daily if tolerated, along
with diet and exercisechange
E. Performa glucose tolerancetest at least 6 weeks after the operation
48
Question
While combing her hair, a 50-year-old woman noticed a swelling in her neck. Although there was
no local pain, shenoted a vague discomfort in the area. She has some difficulty swallowing-
food seemsto stick in her throat. She has also noted some hoarsenessin her voice. She has no
family history of thyroid diseaseand no personalhistory of radiation exposure.
On physical examination, vital signs are normal. She is well developedand nourished.A 3-
cm noduleinvolves most of the right lobe of the thyroid gland. It is quite hard, but it moves with
swallowing.The left lobe is small and soft. No lymph nodes are palpable.
Laboratorytest results indicate that free To and TSH levels are normal. Fine-needle
aspirationbiopsy reveals a very cellular aspirate.Little colloid is present,except in a few dense
clumpssurroundedby follicular cells. There are multiple tiny ringlets of thyroid cells forming
microfollicles,and some "atypical cells" are present.
l(hich one of thefollowing is the most reasonablenext step?

A. Administer suppressivedosesof To
B. Measureserumthyroglobulin severaltimes over the next few months
C. Performsurgery
D. Give radioiodine
E. Performa radioiodine scan of the thyroid gland
49
Question
You are askedto seea l9-year-old man for the evaluation of Cushing qmdrome. Two months
ago,he developedsigns and slirnptomsof Cushing syndromethat have been progressingrapidly
andtheseinclude rounding of his face; thick, purple-red striae over the abdomen,inner thighs,
andaxilla; diffirse acne; and proximal muscle weakness.He has seenseveralphysicians with no
diagnosis.His sister found a dtlscription of Cushing syndrome on the Internet and told her brother
thathe must have the disorder.He has also recently been diagnosedwith hypertension.Current
medicationsinclude metoprolol, 100 mg daily, and enalapril, 5 mg daily.
On physical examination, BMI is28.2kg/m', blood pressureis 139/95 mm Hg, and heart rate
is 50 beats/min.His face is full, round, and red. He has moderateacne distributed over his face
andback.There are purple-red striae measuring 1.5 to 2.0 cm in width in the axilla and on the
lateralabdomenand inner thighs. His proximal muscle strength is good and he can easily do deep
kneebends.Small dorsocervical and supraclavicularfatpads are evident.
ESAP
2S10*QUE$Ttoil$
41
\

Blood:
Sodium: l4l rr.lBq/l-
Potassium:3.6 mEqlL
Calcium: 9.8 mg/dl
Glucose: 115mg/dl
Aspartate aminotransferase: 3l UI-
Cortisol (8 AM) :30.2 mgldL
ACTH: 115pglml-
Saliva:
Midnight salivary cortisol: 900 ngldl (referencerange <100 ng/dl)
Urine:
Urinary free cortisol :5I2mgl24h
Creatinine : 1200 mgl24 h
of a
Head MRI shows a"2-mrnfocus of T1 hypointensity on the left side of the sella, suggestive
microadenoma."
this patient?
Wich one of thefollowing is the best next step in the evaluation and treatmentof
A. lnferior petrosal sinus sampling forACTH
B. Dexamethasonesuppressedcorticotropin-releasinghormone stimulation test
C. High-dose dexamethasonesuppressiontest
il rln-DTPA-pentetreotide
D. Somatostatinreceptor scintigraphy with
E. Transsphenoidalsurgery for selective adenomectomy
50
Question
you receive a telephonecall from a family physician asking your advice regarding diagnostic
had a large
testing for gestationaldiabetesmellitus. He is concernedbecauseone of his patient's
gestationaldiabetes
baby, and only retrospectively did he realize she must have had undiagnosed
mellitus. He had been in the habit of only testing patients he consideredto be at high risk and
is now considering screeningall his pregnantpatients. Presently,he is caring fot aZ2-yeatold
she has
woman in the 16th week of her first pregnancy.She is white, her weight is normal, and
test
no family history of diabetes.He wants your recommendationsregarding the best screening
for this patient.
Wich one of thefollowing strategies would you recommendto the physician?
of
A. Before 20 weeks' gestation,determinethe plasma glucose level t hour after ingestion
50 g oral glucose
24 and
B. advise that all pregnant women undergo screeningfor gestationaldiabetesbetween
28 weeks'gestation
C. Have the patient monitor blood glucosewith a home meter and then perform screening
if the fasting gluposeconcentrationis greater than99 mgldLor the 2-hour postprandial
concentrationis greaterthan 119 mg/dl
D. Tell him that becauseof her low risk, this patient should not be screenedunt1l32 weeks'
gestation
E. iell him this specific patient doesnot need screeningfor gestationaldiabetes
2010*QUESTIoNS
42 ESAP
Question
51
A 40-year-oldman describesof 3 weeks of nauseaand vomiting and has a blood calcium

concentration of 13.7 mgldL. His history is unremarkable,exceptfor the removal of a benign
fibroustumor from his mandible 4 years earlier, which had been identified on a dental x-ray.
Whenquestionedabout his family history he statesthat his father and paternal aunt both had
surgeryto treat primary hyperparathyroidism.Neither the patient nor any family member is
reportedto have pituitary or pancreaticneuroendocrinetumors. The patient takes no medications
or vitamins.He hashad no spellsor history of hypertension.
On physicalexamination,blood pressureis 120180mm Hg; upon standing,it decreases
to 100/60mm Hg. A firm, l-cm nodule in the right thyroid lobe is detected.Findings from his
examinationare otherwise unremarkable.
Laboratory
testresults:
Hemoglobin: ll.9 gldL
Glucose:90 mg/dl
Serumureanitrogen:30 mgldL
Creatinine: 1.4 mgldL
Albumin:2.8 gldL
PTH: 420 pglmL
Calcitonin: l0 pglml-
TSH:0.5 mIU/L
Prolactin: l0 ns/ml
Thyroid scanshows a "cold" nodule in the right upper lobe of the thyroid gland.
Whichone of thefollowing is the most likely diagnosis?

Familial isolated hyperparathyroidism
Multiple endocrineneoplasiatype I
Multiple endocrineneoplasia type 2
Familialbenign hypercalcemia(familial hypocalciurichypercalcemia)
Hyperparathyroidism-jaw tumor syndrome
Question
52
A 43-year-oldman with a gender identity disorder visits your office regarding endocrine
manipulationsfor his cross-sexhormone treatment.
Up until his appointment with you, he has worked with his primary care physician, a local
psychiatrist,and a number of other allied health professionalsin preparing for this intervention.
During the evaluation, he was noted to have a medical history that included a deep venous
thrombosisat age3l years after an extendedplane flight. He was treatedwith anticoagulantsand
hadno residualsequelae.He has no family history of hypercoagulabilityor bleedingdisorders.
Evaluationby his primary care physician showed normal findings from coagulation studiesand
a normalbleedingtime. His plateletcount is normal. On physical examination,he is healthy
without abnormal findings.
Cyproterone acetateis not currently approved for use in the United States,but is a
progestationalagent with potent antiandrogenicactions that has been used in rnale-to-female
transgenderheatment in Europe.
tr$&p*s'!s**!.jffisT$*i\{$43
Assuming cyproteroneacetate is available to you, which one of thefollowing treatmentsin
conjunction with this drug will most safely and effectively result in the desired changesin
secondary sexual characteris tics?
A. Orchidectomy
B. Oral medroxyprogesteroneacetate
C. Oral l7B-estradiol
D. Oral ethinyl estradiol
E. Raloxifene
53
Question
A 38-year-old man presentswith concernsabout the gradual onset of impotence and decreased
libido over the last 3 years. He has had mild, intermittent headaches,but no vision problems. He
has fathered 2 children. Findings from his physical examination are normal except for minimal
gynecomastia.Testicular size is normal.

FSH: <3.OIU/L
LH: <3.OIU/L
Prolactin:37 nglmL
Testosterone: 135 ng/dl
MRI of the head showsa3.2 x 1.6 x 2.3-cm sellarmasswith extensionboth into the suprasellar
areawhere the mass abuts the optic chiasm and into the left cavernoussinus where the tumor is
partially wrapped around the left internal carotid artery.Visual fields show mild supertemporal
field deficits.
Wich one of thefollowing options is the most appropriate next step?

A. Refer for transsphenoidalsurgery
B. Refer for gamma knife radiotherapy
C. Remeasurethe serum prolactin concentrationat a dilution of l:100
D. Measure o-subunit of pituitary glycoprotein hormones
E. Treat with long-acting octreotide
54
Question
A 34-year-old woman comes to your office with a chief concern of secondaryamenorrhea.The
patient had menarcheat age 12 yearsand previously had regular cycles. She had a term vaginal
delivery 4 years ago and breastfedthe infant for 5 months.After the birth of her child, she took
oral contraceptivepills until 13 months ago when she began to prepare to attempt a second
pregnancy.She has not had a period since discontinuing birth control. Recently, she has noticed
increaseddifficulty sleeping and pain with intercoursebecauseof vaginal dryness. She reports
mild fatigue. She statesthat she has gained 10 pounds since the birth of her child. She has no
headaches.
Medical history is notable for mild hypertensionand hypercholesterolemiathat is managed
with diet and exercise.She is not taking any medications. She had an appendectomyat age 18
years. Her first pregnancywas complicated by gestationaldiabetes.Results from a postpartum
2-hour oral glucose tolerancetest were normal. Social history is notable for an occasionalglass
of wine at social events. She exercises3 times a week at the local gym. Her father recently died
of a myocardial infarcti on at age73 years; her 67 -year-oldmother has hypothyroidism. Her
brother was recently prescribedatorvastatinfor hypercholesterolemia.
44 ss,{P?010*QUE$T|0N$
On physicalexamination,she is 67 inchestall and weighs 141pounds(BMI : 22.1kglrfi).
Bloodpressureis 134189mm Hg. Physical examination findings are notable for grossly intact
cranialnerves,a nonpalpablethyroid gland, and no acanthosisnigricans. Breastsare symmetric
Tannerstage5 without massesor nipple discharge.She has normal female hair distribution with
a few periareolarhairs. Pelvic and bimanual examination findinss are normal.
Fastingblood glucose: 102 mgldL
TSH: 4.2mlU/L
Prolactin: 12nglmL
FSH: 43.5IUIL
LH:26,7IUIL
Estradiol: 12pglmL
Total testosterone: 26 ng/dL
Transvaginalultrasonographyshows a normal anteverteduterus with an endometrial stripe of 3

mm. The ovariesare noted to have only a few visible antral follicles with ovarian volumes of 4.4
cm3on the left and3.7 cm3on the right.
Whichone of thefollowing is the most likely diagnosis?

A. Hypothalamicamenorrhea
B. Hypothyroidism
C. Polycysticovary syndrome
D. Prematuremenopause
E. Post-pillamenorrhea
Question
55
A patientwith type 2 diabetesmellitus is now in her 38th week of pregnancy.Her pregnancy
hasbeenuneventful, but the fetus is macrosomic on ultrasonogtuphy (estimated*Light of 4600
g). Becauseof uncertain pregnancy dating, her obstetricianperformed an amniocentesisand has
documentedfetal lung maturity. He has planned a cesareandelivery for tomorrow and would
like someguidanceregarding insulin managementbefore and after the operation.The patient's
glucoselevels have been under good control, and her current insulin dosageis 80 units of NpH
insulin/48units of regular insulin each morning, 38 units of regular insulin before dinner, and,44
unitsof NPH insulin at bedtime.
Wich one of thefollowing do you recommendfor her insuliin dosesbefore and after operation?
A' Usualbedtime NPH dose the night before sugery; withhold insulin the morning of surgery.
Intraoperativemonitoring to maintain glucose in the 70 to 120 mg/dLrange. postoperatively,
regularinsulin given as neededfor the first24 hours to maintain fasting glucose
concentrationless than 180 mgldl.
B' Usual bedtime NPH dose the night before surgery; then withhold insulin the morning of
surgery.Start prepregnancyinsulin dosageson postoperativeday 1
C' Usualbedtime NPH dose the night before surgery and half of her usual morning NpH and
regularinsulin dose on the morning of surgery.Sliding scale dosesduring her postoperative
courseto maintain fasting glucose concentrationless than lg0 mg/dl
D. Usualbedtime NPH dose the night before surgery; withhold insulin the morning of surgery.
Resumeusual pregnancy dosageson postoperativeday I when she is likely to begin a diet
E. Admit the patient for overnight observation,then withhold all long-acting insulin and use
short-actinginsulin every 2 to 4 hours as guided by fingerstick glucose monitoring
H$Ap3&10*frUtr$Tt$ru$
45
Question
56
467'yeat-old man with chronic, stable angina pectoris is referred for evaluation
and treatment
of hypothyroidism. Cardiac catheteization 6 months earlier revealed single-vessel
(left anterior
descendingartery) coronary disease.The patient has been taking atenoloi, 100
mg daily by
mouth, and aspirin, 81 mg daily, with only rare episodesof exercise-induced
ungiru.
He is symptomatically hypothyroid with fatigue, muscle aches,constipation,
and dry skin.
On physical examination, blood pressureis l32l92mm Hg and pulse rate is
64beats/minwith
occasionalpremature contractions.The skin is dry and there is periorbital
edema.Deep tendon
reflexes show marked delay in relaxation phase.

HDL cholesterol : 34 mg dL
LDL cholesterol : 246 mg dL
Serum total cholesterol: 420 mgldL
Serum TSH : 62 mItJlL
Serumfree To :0.4 ngldL
Which one of thefollowing is the best therapeutic option?

A' Administer prophylactic anticoagulationtherapy and begin thyroid
hormone replacement
with levothyroxine, 100 mcg daily
B' Begin thyroid hormone replacementwith levothyroxine, 75 mcgdaily,
and liothyronine,
25 mcg daily
C' Begin thyroid hormone replacementwith levothyroxine, 100 mcg daily,
and begin cortisone
acetate,3Omg daily
D. Begin thyroid hormone replacementwith levothyroxine, 100 mcg daily
E. Begin thyroid hormone replacementwith levothyroxine,25 mcg daily
Question
57
You areaskedto seea 73-year-oldpostmenopausal womanfor osteoporosis.Thebonemineral

densityresultsareshownbelow.An x-ray confirmsTl2 and,Ll compression fracfuresthat
weretreatedwith vertebroplasty.
Shehasa historyof diabetesmellitus.Chronickidneydisease
hasbeendiagnosed, andshewill needhemodialysisin the future.Shealsohasa historyof
anemia,hyperlipidemia,andhypothyroidism. Medicationsincludeinsulin,nifedipine,enalapril,
lorazepam,levothyroxine,
pentoxi$zlline,aspirin, andacombinationof B vitamins.
Laboratorytestsresults:
Glucose: 133mgldl,
Sodium: 138mEq/L
Potassium:4.8mEq/L
Chloride:98 mEq/L
Bicarbonate: 32 r-nBq/L
Serumureanitrogen:29 mg/dL
Creatinine:2.8 mgldL(glomerularfiltrationrate:20.4 mllmin)
Calcium:8.6mg/dl
Albumin:3.6 g/dL
Alkalinephosphatase : 172U/L
46 E$A,P
201o*QUr$n0N$
Aspartateaminotransferase: 15UIL
:
Alanineaminotransferase2l UIL
PTH: 648pg/mL
25-HydroxyvitaminD : 7 ndnL
1,25-DihydroxyvitaminD, : 7 pglmL
TSH: 1.1mIU/L
YounsAdult Ase-Matched
BMD,
Resion plcm2 o/o T score "/" Z score
L1 t.192 105 0.5 135 2.6
L2 0.732 61 1.9 77 .8
L3 0.768 64 -3.6 8l .)
L4 0.814 68 -a.z 85 .2
L2-L4 0.770 64 1.6 8l .5
Youns Adult Ase-Matched

BMD,
Resion sJcm2 o/
T score Vt Z score
Neck 0.289 28 -5.4 38 _J.J
Total 0.306 30 -5.6 40
Wich one of thefollowing medications would you prescribe?

A. Alendronate
B. Ergocalciferol
C. Calcitriol
D. Raloxifene
E. Cinacalcet
58
Question
A 54-year-oldman was recently diagnosedwith type 2 diabetesmellitus when an elevatedplasma

glucoselevel was documentedduring a routine medical evaluation. He is sedentary smokes 1
packof cigarettesper day, and is overweight. He has no other medical illnesses,and except for a
multivitamin, he takes no medication. There is a family history of type 2 diabetesmellitus in his
motherand I of his older sisters.
He weighs 192 pounds(BMI : 28.3 kglnf), and blood pressureis 145/88mm Hg.
47
ESAP2O1O-QUESTION$
\

HDL cholesterol : 37 mgldL (desirable for patient with diabetesmellitus, >45 mgldL)
LDL cholesterol : l4l mgldL (desirablefor patient with diabetesmellitus, <100 mg/dl-)
Triglycerides = 210 mg/dl
Hemoglobin Ar":8.2o/o
Fasting glucose : 144 mgldL
Wich one of thefollowing would you recommendfor initial therapy?

A. A 3-month trial of lifestyle changewith referral to a dietician and detailed discussionof
smoking cessationtogether with considerationof statin therapy
B. Metformin, 500 mg twice daily, progressingto 1000 mg twice daily if tolerated plus
lifestyle change
C. Glyburide, 5 mg twice daily, with lifestyle change
D. Pioglitazone,30mg daily
E. Exenatide, 5 mcg subcutaneouslytwice daily
59
Question
A7l-year-old woman is referred for evaluation of an incidentally discoveredright adrenal mass

noted I year ago when an abdominal CT scanwas performed to investigateleft-sided abdominal
discomfort. She has no history of malignancy, and findings from a recent mafirmogram are
normal. She has a l7-year history of hypertension.Her medications include amlodipine, 5
mg once daily; metoprolol, 50 mg twice daily; furosemide, 20 mg once daily; and potassium
chloride,20 mEq once daily.
On physical examination, she is overweight (BMI : 29.2kglm2). Blood pressureis 144184
mm Hg (right arm) and 140/80 mm Hg (left arm), and heart rate is 64beatslmin. She appears
well. The heart soundsand findinss from abdominal examination are normal.

Sodium: 138 mEq/L
Potassium:4.0 lraBqL
Plasma fractionated free metanephrines,within the referencerange
Plasmaaldosterone: 10 ngldl
Plasmarenin activity : 1.6 nglml- per h
Serum cortisol at 8 AM (1-mg overnight dexamethasonesuppressiontest) : 1.6 VgldI-
DHEA-S, within the referencerange
The findings from initial abdominal CT show a 1.8-cm nodule (28 Hounsfield units on
noncontrastimage) containing a small central calcification in the right adrenal gland and a
normal left adrenal gland. Findings on follow-up Cl now 1 year later, show that the right
adrenalmass has grown to 2.9 cm, and there is less than 50o/ocontrast medium washout at 10
minutes after contrast material administration.
I,
h 48 ESAP2O1O-QUESTIONS
llhich one of thefollowing is the best next step in this patient's care?
A. Resectthe right adrenalmass
B. Perform l23l-metaiodobenzylguanidinescintigraphy
C. PerformCT again in 1 year
D. PerformCT-guided fine-needle aspiration biopsy
E. No further follow-up is needed
60
Question
You areaskedto seea 32-year-old woman inher Z9thweek of pregnancy for hyperlipidemia.
Shepresentedthe day before with vaginal bleeding and uterine contractions and was admitted
for observation.
Theseproblemsabated,but a blood samplecollectedwhile fastingwas lipemic,
promptingthe requestfor endocrine evaluation.
Shehasbeen in general good health with no chronic conditions requiring medication. Her
pregnancyhasbeen unremarkableexcept for weight gain greaterthan recommended(33 pounds).
Shehasbeenfollowing an unrestricted diet. The patient has no history of hyperlipidemia,
hypertension,or diabetes(including during a previous pregnancy when she had a formal
evaluationfor gestationaldiabetes).She reports a healthy childhood with no abnormalities of
growthand development.She has no history of recurrent gastrointestinalsymptoms, abdominal
pain,or pancreatitis.She is unsure whether there is a history of hyperlipidemia in her family
members.
On examination,she is 66 inches tall and weighs 200 pounds (BMI : 32.3 kglm2). Blood
pressureis 96157mm Hg. She has severalclusters of eruptive xanthomataacrossher back and on
thedorsalaspectsof her arms. The abdomenis gravid but not tender.
Laboratorytest results from a blood sample collected while fasting:

Glucose:76mgldL
TSH: l.2mIUlL
Herbloodglucoseconcentration60 minutesafter a 50-g oral glucosedrink was l2l mgldL at 27

weeks'sestation.
ffi$Ap**'t{}.**tiffi$?$*$i$ 49
Wich one of thefollowing is the best next step in management?
A. Gemfibrozil
B. Fat-restricteddiet
C. Total parenteralnutrition with minimum fat
D. Simvastatin
E. Plasmaapheresis
Question
61
422-year-old woman presentswith a l-year

history of amenorrhea.Menarche occurred at age
14 years. Menseshave always been irregular, but
she has never experiencedsuch a long period of
amenorrhea.In addition to measuring LH, FSH,
and estradiol, which togetherpoint to a diagnosis
of hypogonadotropichypogonadism,MRI is
performed. A representativecoronal view after
gadolinium administration is shown.
Although prolactin is within the reference
range (4 nglmL), the fasting growth hormone
concentrationis I I nglmL. When questionedabout
physical changes,the patient reports that her hips
and abdomenhave gotten 'ofatter.,,Her serum IGF-l
concentrationis 64 ng/mL, and an 8 AM serum
cortisol concentrationis 30 pgldL. On physical
examination, she is 64 inches tall and weighs 95
pounds (BMI : 16.3 kglm2).
Wich one of thefollowing should you do now?
A. order a 2-hour oral glucose tolerancetest for growth hormone
B. Test formal visual fields
C. MeasureAM and PM salivary cortisol
D. Send her to a neurosurgeon
E. Refer for behavioral evaluation
Question
62
A 78-year-old man is admitted to the hospital after 4 days of vomiting and
confusion. He has
smoked cigarettesfor many years and has a medical history that includes
chronic bronchitis,
angina pectoris, hypertension,and mild congestiveheart failure, all of
which are stable on a
regimen of isosorbidedinitrate, 10 mg four times daily; lisinopril, l0 mg
daily; and fryosemide,
20 mg daily. His daughtertells you that he has had a ltw-grade fever,
diffirse myalgias, and a
modest increasein his cough over the last severaldays. The day before
comingio iire hospital,
he becamelistless, beganfo urinate more often, and startedvomiting.
on examination today, he no longer knows his name, the date, or where he
is. He can
converse,but appearssomewhat somnolent.He is clinically dehydrated.Blood pressure
is
120170mm Hg, and it falls to 100/70 mm Hg upon standing.The examination
is otherwise
unrevealing.
Hematocrit:49%
t 50
white blood cell count : l0,60altrL with 90vopolymorphonuclearcells
t
HS,AP
?O1O-QUESTION$
Sodium: 135mEqll-
Potassium :3.4 mEqL
Chloride:90 mEq/L
Bicarbonate:29 mEilL
Serumureanitrogen :40 mgldL
Calcium: 16.5mgldL
Phosphorus: 4.0 mgldL
Albumin:4.0 gldL
Measurements of blood gasesand pH are unchangedfrom his usual status(Po, : 70 mm Hg;

Pcor:45 mm Hg; pH: 7.38).A chestradiographshowsno acutechanges.Blood is sentto the
laboratoryfor measurementof serum PTH.
Therapyis initiated with normal saline at200 mLlh, with 40 mEq KCI in each liter. After
1500mL of fluid administration, he no longer shows a postural changein blood pressure,and his
serumcalcium concentrationhas fallen to 15.6 mg/dl. His serum albumin concentrationis now
3.8g/dl. There are no clinical signs of congestiveheart failure.
Salmoncalcitonin,4.1IUlkg, is administeredsubcutaneously along with furosemide,40 mg
intravenouslyas a single dose.The intravenousinfusion is continued as 5%oglucoselhalf normal
salineat 300 mllh. His serum calcium concentrationis unchanged4 hours later.
Wich one of thefollowing should be the next step in his therapy?

A. Administration of 8 to l0 L of half-normal saline, with potassium,magnesium,and
furosemideas needed,over the next 24 hours
B. SameasAnswerA, with a doubling of the calcitonin dose,administeredsubcutaneously
every 12 hours
C. Hemodialysis
D. Emergencyparathyroidectomy
E. Administration of pamidronate,90 mg intravenously,along with continued administration of
4 L of half-normal saline, with potassium,magnesium,and furosemide as needed
63
Question
A 46-year-oldwoman underwent Roux-en-Y gastric bypass4 years ago to treat medically
complicatedobesity. She weighed 300 pounds at the time and was hypertensive.Since then,
shehaslost approximately 140 pounds and takes atenolol for her hypertension.This is her only
medication.For the past 4 weeks, she has been troubled by symptoms of tachycardia,tremor, and
diaphoresis.These symptoms are aborted by drinking orangejuice. A home reflectanceglucose
meterreports glucose readings in the 40 to 50 mg/dl range at the time of symptoms, which tend
to occur in the late morning, 3 to 4 hours after breakfast.A 75-g oral glucose tolerance test is
performed.The result is consideredpositive becausethe patient develops symptoms 90 minutes
afterglucoseingestion.Heart rate is 110beats/min,and blood pressureis 145195mm Hg.
Laboratorytest results 90 minutes after administration of 75 g of oral glucose:

Glucose:39 mgldL
C-peptide:3.3 nglmL
Insulin: 10 pIU/mL
Postbariatrichypoglycemia is presumptively diagnosed,and the patient is referred for evaluation

andmanasement.
51
ESAP201O*QUE$TIONS
Wich one of thefollowing would you do now?
A. Perform a selective arterial calcium stimulation test to direct gradient-guided partial
pancreatectomy
B. Perform another glucose tolerancetest, but this time, do a sulfonvlurea screen
C. Prescribeacarbose
D. Prescribediazoxide
E. Ask a pharmacist to review all her medications
Question
64
During a routine office visit for managementof type I diabetesmellitus, a 30-year-old man also
describesright scrotal fullness. He thinks that this has developedin the past month, but reports
no pain, fevers, or chills. He admits that he 'ohadn'treally checked" before, but that his girlfriend
noticed the asymmetry He has no history of testicular or scrotal trauma. He is sexually active
and has no symptoms of erectile dysfunction or altered libido. There has been no changein the
rate of facial hair growth.
He has had diabetes for 20 years and has been treated with an insulin pump during the last
4 years with moderateto good control and hemoglobinA," values between 7o/oand,8.2%.With
regard to complications, he has had photocoagulationtherapy to both eyes,although retinal
examinationsnow show his condition to be stable, and he has no evidence of active retinopathy.
He has proteinuria-roughly I gl24 h-and is treatedwith lisinop1ll,40 mg daily. His LDL-
cholesterol levels have been less than7} mgldL. He does not take aspirin, and he has not been
treated with a statin.
Physical examination reveals a healthy young man in no apparentdistress.Blood pressure
is 128178mm Hg with a restingpulse rate of 80 beats/min.He is 71 inchestall and weighs 171
pounds (BMI : 23.8kglm2). Other than photocoagulationtherapy scars,examination findings
of his head, eyes, ears,nose, and throat are normal. Findings from pulmonary, cardiac,and
abdominal examinationsare nonnal. His extremities reveal l+ pretibial edemabilaterally. He has
a normal phallus and pubic hair on genitourinary examination. Both testesare normal size. The
right scrotum is larger than the left scrotum, and with the patient standing,you are able to palpate
the cord structures,revealing a"bagof woms." There is minimal tenderness.With the patient
supine, you again examine the scrotum and the findings are unchanged.
Wich one of thefollowing evaluations is the best next step?

A. Semenanalysis
B. Right testicularbiopsy
C. LH, FSH, and testosteronemeasurements
D. Serum protein and urine protein electrophoresis
E. Doppler ultrasonographyof testesand testicular vasculature
Question
65
You are askedto see a26-yearold woman for evaluation of weight gain. She is 63 inches tall
and weighs 240 pounds (BMI : 42.5 kglm2). She reports gaining 50 pounds over the last 3 years
since the birth of her secondchild. Her parentsare both overweight, but her 2 siblings are not.
She has no other medical problems. She takes no medications,does not smoke cigarettes,and
drinks alcohol only occasionally.
Blood pressureis normal. She has central fat distribution, but no buffalo hump or increasein
supraclavicularfat. She has severalthin pale striae along the lower abdominal wall and breasts.
She has no telangiectasia,acne, or hirsutism. Her proximal muscle strength is normal.
52 H$Ap*01S*QUn$TtSN$
Whichone of thefoltowing best explains her obesity?
A. Decreased leptin
B. Defectiveaction of uncouplingprotein 3
C. Increasedcaloric intake
D. OccultCushingsyndrome
E. Hypometabolism
Question
66
A25-year-oldman with a 9-yearhistory of type I diabetesmellitus

returnsfor routine fbllow-up
6 weeksafterbeginningthe use of his continuousglucosesensor.
He hasbeen frustratedwith his
inabilityto maintaina hemoglobll A,. level tnder 7.0%odespitefrequent
glucosemonitoring and
completeadherenceto his prescribedinsulin regimen,including frequent
correctiondoses.He
eatsregularmealsand doesnot snackafter dinner.He has experienced
no chronic complications
ofdiabetesorseVereepisodesofhypoglycemiarequiringassistance.
His insulin regimenincludesinsulin glargine,26 uniis at bedtime(around
l l to l l:30 pM),
andinsulinglulisine, I unit per 16 g carbohydratefor breakfastand
lunch and I unit per 13
g carbohydrate for the eveningmeal. He usesa conection doseof I unit per 45 mgldL,
with
a glucosegoal of less than 120 mgldL for corrections.The combined
bolus dosesfor the day
averageabout2I units. He takesno other medications.
on physicalexamination,blood pressureis 122176mm Hg, and pulse
rate is 65 beats/min.
He is 70 inchestall and weighs 161pounds(BMI : z3.t kghi). Funduscopic
examination
showsno evidenceof diabeticretinopathy.The thyroid gUna ls normal
in size without nodules.
Findingsfrom neurologicexaminationare normal. His skin has
no vitiligo or hyperpigmentation.
Potassium :3.9 mEqlL
Hemoglobin A*:7.6oh
Albumin to creatinineratio: 7 pglmg
TSH: 1.4nIUIL
Youreviewthe self-monitoredglucoseprofile, which showsthe following

resultsfor the 4 days
of thepresentcontinuousglucosesensor.There is a high correlation
with self-monitoredblood
glucosevalues.
I P?EmeNl
&Eultndor${bothmodrnd cffiscllofil
I Corudlandore{ons
r50rfltil" -^.-",-""-
tr-1
- Dryr
--" Eryz
.....,...DryS
*.. Day4
rt {*t t2 tftt
ffi$&p
x*"{****K$Y{*ru$ 53
Considering this glucoseprofile, v,hich one of thefollowing changesto the insulin regimen would
be most appropriate?
A. Increaseinsulin glargineto 30 units
B. Split the insulin glargineinto l3 units in the morning and 13 units in the evening
C. Changethe timing of the insulin glarginedosefrom bedtimeto moming without dosage
change
D. Increasethe carbohydratecountingratio to I unit per 10 g of carbohydratefor the evening
meal
E. Changeinsulin glargineto insulin detemir at the samedosage
67
Question
A 39-year-oldman is referredto you becauseof
osteoporosis. At a health fair, bone densityof the heel
assessed by ultrasonographywas low. He has no notable
medical history but doeshave a family history of
osteoporosis.He doesnot smokecigarettesand doesnot
consumemuch alcohol.
On physical examination,blood pressureis 120174mm
Hg, and heartrate is 68 beats/min.He weighs 180 pounds.
Scleraeare white. He has no signsof Cushingsyndrome,
but he has a diffuse macularrash,especiallyon his trunk,
with a positive Darier sign and associatedpruritus.A
photographis shown.
DXA bone mineral densitvmeasurements:

BMD,
Reqion plcmz T score Z score
L1-L4 0.746 2l
3.0
Hip 0.84',7 1a 0.8
Femoralneck 0.663 -2.0 t.4
After reviewing normal valuesfrom a completeblood cell count and measurementof

electrolytes,serumurea nitrogen,creatinine,calcium, and albumin, you order additional
laboratorytests.
Which one of thefollowing laboratory test results is most consistentwith this clinicctl scenctrio?
A. Total testosterone- 98 ngldl
B. 25-HydroxyvitaminD - 22 ng/ml
C. PTH: 65 pglmL
D. Tryptase:78 nglml
E. Calcitonin: 50 pglml
68
Question
You are askedto seea 57-year-oldwoman for evaluationof adrenalinsufficiency.The patienthas
beentroubledby low back pain for 10 years.Shehad receiveddepot-corticosteroid injectionsto
the lumbar facetjoints monthly for 3 months,starting 1 year ago. In addition,to treat her right
shoulderpain, shehad 2 depot corticosteroidinjections I and 5 months ago. For her hip pain, she
had 3 depotsteroidinjections9, 10,and 1l monthsago.
Over the past year, shehas gained42 pounds,and her face has becomemore round and red.
Shehas noted easybruising and symptomsconsistentwith proximal muscleweakness.Because
54 r3
of progressiveweaknessand fatigue, she soughtmedical consultation6 months ago. Laboratory
studiesshowedundetectablelevels of cortisol in the blood and in a24-hoururine collection.In
addition,her serumACTH concentrationwas undetectable. A 250-mcg cosyntropinstimulation
testwasperformed,and her serumcortisol concentrationrose from a baselineof l.l pgldl- to
a peakconcentrationof 5.5 p,gldL.Shewas diagnosedwith adrenalinsufficiencyand treated
initially with hydrocortisoneand prednisone,but theseagentscausedankle edemaand her
conditionwas not improved.The glucocorticoidwas changedto dexamethasone, 0.5 mg daily-
thedosagethat shehas beentaking for the past 5 months.Her proximal muscleweaknesshas
becomeevenmore problematic-she cannotget up the 8-inch stepat the front door of her house.
Shefeels"run down and weak." Except as noted above,the patient indicatesshe is not taking any
otherforms of glucocotticoids(eg, topical or inhaled).Becauseof her progressivefatigue and
weakness, sheis desperatefor a bettertherapyfor her adrenalinsufficiency.Her local physicians
have suggestedsheincreasethe dexamethasone dosage.
Her currentmedicationsinclude dexamethasone, 0.5 mg daily;
carvedilol,6.25 mg twice daily; celecoxib(Celebrex),200 mg
twice daily; gabapentin,600 mg 4 times daily; and omeprazole,20
mg daily.
On physical examination,BMI is 40.8 kglm2,blood pressure
is 137189mm Hg, and heartrate is 88 beats/min.Her face is full
and round (seephotograph).Her skin is not hyperpigmented.
Body weight is centrally distributed; she has relatively thin
extremities.She cannotstandfrom the seatedposition without
using her arms to assist.Small dorsocervicaland supraclavicular
fat pads are evident.
Appropriateadvicefor this patient includes which one of thefollowing?

A. Obtaina pituitary-directedMRI
B. Performa corticotropin-releasing
hormonestimulationtest to assessstatusof pituitary
corticotrophs
C. Obtaina syntheticsteroidscreen
D. Discontinuegabapentin
E. Slowly taperher dosageof glucocorticoidand initiate physicaltherapy
69
Question
A 63-year-oldman was noted to have a pituitary tumor. Becausehis prolactin concentration
wasbetween500 and 700 nglmL, bromocriptinewas prescribed.Although his prolactin level
decreased,it never returnedto the referencerange,and after 2 yearsoftreatment it again
beganto increase,reachinga concentrationof 12,000nglmLdespitea bromocriptinedosage
of 15 mg daily. Cabergolinewas also ineffectivein
lowering serumprolactin.The patientwas experiencing
rapid tumor enlargementthat was causingvisual field
abnormalities.No additionallesionswere noted on
brain MRI. He underwenta transsphenoidal operation
to debulk the tumor, and his vision normalized.The
surgicalspecimenshoweda proliferation of epithelial
cells, and immunohistochemicalstainsrevealed
prolactin in multiple cells. His tumor againgrew from its
postoperative sizeof 2.7 x 1.9 x 3.3 cm to 3.9 x 3.6 x 2.6
cm. The pathologictumor sectionshowsimmunostaining
for Ki67, (brown stain),which showsproliferatine cells.
i 3 i * y r , 1 e- . t l i " , r h
il*hl 55
which one of the.following descriptions best charqcterizes
the tumor/
A. Prolactin-producing pituitarycarcinoma
B. Craniopharyngioma
C. Aggressive prolacrinoma
D. Hypophysitis
E. Metastasisto the pituitary gland
Question
70
You areaskedto seea 5l-year-oldwomanbecauseof a
recentlydiscoveredthyroidnodule.
There is no history of radiationtherapyto the heador neck.
The patientreportsa family history
of thyroid cancerin an aunt.The patientis asymptomatic;
the thyroid nodule was discoveredon
p h y s i c ael x a m i n a t i o n
on physical examination,BMI is 20.2 kglm2 blood pressure
, is 9gl70 mm Hg, and heartrate
is 80 beats/min'The patientappearsthin and fit. There
isa 1.5-cmflrm nodule in the upper-right
lobe of the thyroid gland.No lymph nodesare palpable
in the neck.
Thyroid ultrasonographyis performed.This transverseimage

showsa nodule (arrow) that
measuresl '3 x 0'9 x 0.7 cm (2 of the axesof measurerlent
ur. ihorn by the numberedmarkers
in the left panelgrayscaleimage).A color-flowDoppler
imageof the noduleis shownin the
right panel.
The image is typical of which one ol the./bllowing conditions?

A. Benignthyroid nodule
B. P a p i l l a r tyh y r o i dc a r c i n o m a
C. Acute hemorrhage
D. Subacutegranulomatous thyroiditis
E. Hashimotothyroiditis
Question71
426-year-old woman with a 3-yearhistory of type I diabetes

rnellitusis referredby her
primarycarephysician.At diagnosis,shehad presented
with typical symptomsof weight loss,
polyuria,polydipsia,and fatigue.Sherecallsthat her
initial bliod glucoseconcentrations had
beenhigherthan 700 mg/dl. However,she.didnot require
hospitaladmissionand did quite
well when insulinwas instituted.Sheexperienced a prolongecl honeymoonperiodand became
56
complacent becauseofher steadycontrol. In the last 2 years,she
hasseldommonitoredher blood glucoseand has not followed up
with herphysician.Sherecentlybeganto notice someof the same
symptomssheexperiencedbefore her diagnosisand returnedto
herprimarycarephysicianwho documentedvery poor glycemic
control.He also noted new skin lesionson her legs. She states
theseareasbeganto appearabout I year ago. Her medical history
is otherwiseunremarkable.
Her insulin regimen includesinsulin detemir, 13 units at
bedtime,and insulin aspart,3 units before meals.No correction
dosinghasbeenimplemented.She also takesan oral contraceptive.
On physicalexamination,blood pressureis I l3i7l mm Hg,
andpulserate is 7l beats/min.She is 64 inchestall and weighs I 17
pounds(BMI: 20.lkglm2). Funduscopicexaminationshowsno
evidenceof diabetic retinopathy. The thyroid gland is of normal
sizewithout nodules.Findings from neurologicexaminationare
normal.Skin examinationshowssomewhatinegular, atrophic,
yellow-brownplaqueswith telangiectasias and slightly raised
violaceous rims (seephotograph).
Potassium :4.1mEqlL
HemoglobinAr":9.50/o
TSH: l.l mIU/L
Calcium:9.8 mg/dl
Aspartateaminotransferase : 28 UIL
Alanineaminotransferase : 33 UIL
:
Hematocrit 38.2%
Whiteblood cell count:570011tL
Plateletcount: 231 x l03lpL
In discussingher leg lesions, which one of thefollowing is an ctccuratestatement'?

A. The lesionsare relatedto insulin detemirand shouldresolvewith conversionto insulin
glargine
B. Treatmentwith intradermalsteroidsresolvesthe lesionsin many cases
C. The lesionsare a consequenceof poor glucosecontrol and shouldimprove or resolve
with bettercontrol
D. The lesionsare autoimmunein natureand are found in type I diabetesmellitus, but not in
type 2 diabetesmellitus or maturity-onsetdiabetesof the young
E. The primary risk is ulcerationof the lesionsfollowing minor trauma
72
Question
A 35-year-oldwoman is referredto you for an enlargingnodule in a long-standingmultinodular
goiter.Over the last year, shehas noted a painlessenlargementon one side that hasnot changed
in sizeduring the last severalmonthS.Shefeels "neck pressure"with swallowing,but has no
dysphagia,cough,or shortnessof breath.She saysthat previousthyroid testinghas always shown
normalthyroid function. Shehas no hyperthyroidor hypothyroid symptoms.Shehasno history
of headand neck radiationor family history of thyroid disease.
Laboratorytest resultsfrom her primary carephysician'soffice include a TSH concentration
of 1.4mIU/L and a freeT, concentration of 1.8ng/dl.
;*'1***Li#sYi*rus 57
{$,&p
\
Physical examination reveals a clinically euthyroid woman with a normal voice. A

multinodular goiter with a 6-cm, very firm, ovoid mass in the right lobe of the thyroid is found
on neck examination. The thyroid is freely mobile with swallowing. No cervical adenopathyis
palpated,and a Pembertonmaneuver is negative. Fine-needleaspiration biopsy reveals 6 mL of
clear yellow fluid.
After removal of the fluid, only a small l-cm nodule is palpated,and a biopsy is performed.
Analysis of the biopsy specimenreveals histiocytes, hemosiderin-ladenmacrophages,a
small amount of colloid, and scant numbers of normal-appearingfollicular cells arrangedin
monolayered sheets.The patient is not given thyroid hormone supplementationand returns in 4
weeks. She says that the nodule increasedto its original size within 2 to 3 daysafter the biopsy.
There has been no worsening of her obskuctive symptoms.
Wich one of thefollowing is the appropriate managementplan?

A. Aspirate the cyst again
B. Aspirate the cyst again and instill ethanol
C. Prescribethyroid hormone suppression
D. Recommend surgical removal of the cyst
E. Observethe patientclosely
73
Question
A 55-year-old man comes to you becauseof recurrent kidney stones.Twelve years ago he passed
a stone of uncertain composition. Two months ago, he passeda stonethat was made of calcium
oxalate. His history is notable for sarcoidosis20 years ago, which presentedwith bilateral hilar
adenopathyand interstitial lung disease.His pulmonary function and findings from chest x-rays
have been stable,and he no longer has hilar adenopathy.He smoked 1 pack of cigarettesdaily
fot 20 years, but has not smoked in the last 20 years.He does not take vitamin D or calcium
supplementsand eats few dairy products. He makes no particular effort to stay well hydrated.
He has had no fractures.Findings from the rest of his history and physical examination are
noncontributory.
L,aboratorytest results:
1,25-Dihydroxyvitamin D, : 120 pglmL
PTH: l0 pglml.
TSH: 1.0mIU/L
Albumin :4.0 gldL
Calcium:10.6 mg/dl
Serumurea nitrogen:20 mgldL
Routine urinalysis, normal
Urinary calcium : 520 mgl24h
Urinary creatinine: l.l gl24h
In addition to increasing hisfiuid intake,you should prescribe which one of the

following?
A. A glucocorticoid
B. Athiazide
C. Nasal calcitonin
D. A low-oxalatediet
E. Potassiumcitrate
58 ESAp2{]*0*QtiEsTt0r,is
A^,
74
Question
A 56-year-oldman presentsfor managementof his abnormallipid profile. He has a l5-year

historyof elevatedtriglyceridesand cholesterol.His first symptomsof coronaryheart disease
appeared at age49 years, and he had coronary artery bypass surgery at age 54 years. He
previouslytried severallipid-lowering medicationsto treat his dyslipidemia,but has takenno
medicationfor the past 18 months. The patient reports that he has 2 older brothers who have not
hadheartdiseaseand that both his parentslived until their late 70s when they died of cancer.He
quit smoking9 years ago and drinks alcohol-containing beveragesonly occasionally.
BMI is 29 kglm2and waist circumferenceis 40 inches.Blood pressureis 12618lmm Hg. A
cornealarcusis present.The thyroid gland is palpable, but not enlargedor nodular. Findings from
examinationof the chest and abdomen are nonnal. There are erythematous,coalescingnodules
on both elbows and an orange hue to the palmar creases.
Triglycerides: 525 mgidl
VLDL cholesterol:365 mgldL
Giventhepatient's medical history,findings from thephysical examination, and lipid

concentrations,which one of thefollowing complications is he most likely to develop?
A, Stroke
B. Type2 diabetesmellitus
C. Cholecystitis
D. Pancreatitis
E. Peripheralvasculardisease
75
Question
{A2-year-old man has had type 1 diabetesmellitus for 16 years. He now has concernsof
persistentnausea,vomiting, and early satiety.As a consequence,his diabeteshasbeenpoorly
controlledand he hasbeenhaving episodesof both hyperglycemiaand hypoglycemia.His
currentregimenconsistsof 30 units of a 70130insulin mixture beforebreakfastand l8 units
beforedinner.Other medicationsinclude omeprazole,metoclopramide,and lisinopril.
Bloodpressureis 135/88mm Hg, and heartrate is 85 beats/min.He weighs 140 pounds
andis 69 inchestall (BMI :20.7 kglm'z).Funduscopicexaminationrevealsonly background
retinopathy.His Achilles tendonreflexesare absent,and thereis a bilateraldecreasbin light touch
andpainsensationfrom the mid-calf distally.Monofilamenttestingof his feet showsabsent
sensation.
Serumglucose(fasting):238 mgldL
HemoglobinAr,: Il.2o/o
Serumcreatinine: 1.1 mg/dl
Urinaryalbumin :250 p"gl24h
Gastricemptyingof liquid and solid, assessed

with a radionuclidestudy,is normal.
WffiX4W
X*3***q*X&71*N* 59
Wich one of thefollowing is the most reasonableprocedureto perform next?
A. Gastroscopy
B. Mesenteric angiography
C. Another gastric emptying study, ensuring that the blood glucose concentrationat the time of
the study is lessthan 180 mgldL
D. Abdominal CT
E. Abdominal MRI
76
Question
A 30-year-oldman presentswith decreasedlibido, energy,and frequencyof morning erections.
He hashad recentonsetof polydipsia and occasionalnocturia,but reportsno other symptoms.
Pubertal developmentwas normal.
He is not taking any medications, statesthat he does not use alcohol or other drugs, and has
no notable medical or surgical history. He and his wife are interestedin starting a family in the
near future.
Physicalexaminationrevealsa normally virilized man without gynecomastia.Blood
pressureis 122182mm Hg, and heartrate is 70 beats/min.Findings from cardiac,pulmonary
and abdominal examinationsare normal. Visual fields are intact to confrontation. Testesare
20 mL bilaterally with no masses.Examinationof his skin showsno spiderangiomataor
hyperpigmentation.
TSH: l.2mIUlL
Free T, : 1.2 ngldL
FSH:2.2IUIL
LH: 0.6IU/L
Prolactin: 5.6 nglmL
Total testosterone: 179 ngldL
Glucose(fasting): 190 mg/dl
Semenanalysis reveals normal volume with decreasedcount per mL, decreasedmotility, and
low percentagewith normal morphology (oligo-azoo-asthenospermia).Pituitary MRI showsno
abnormalities.
Wich oneof thefollowinginvestigations wouldmostlikely leadto a specffic

or measurements
diagnosis?
A. Testicular
biopsy
B. Serumferritin
C. Karyotypeanalysis
D. AcuteGnRHtestfor LH responsiveness
E. Seruminhibin B concentration
77
Question
A77-year-oldnursinghome residenttakes88 mcg of levothyroxinedaily for managementof
primary hypothyroidism.Shehas not been seenby you in 7 months.The patient is sentto the
emergencydepartmentbecauseof confusion. She arrives at the hospital in a somnolent state
and with a Foley catheterin place. The nursing home record indicates that the patient refused
to eat for a week and had body temperaturesof 95'F. Aside from thyroid hormone,the patient's
medications include a thiazide diuretic, donepezil (Aricept), and duloxetine (Cymbalta).
60 ESAP201O*QUESTIONS
The patient can barely be roused.Blood pressureis 84/40 mm Hg, heart rate is 70 beats/min,
andrespirationsare 12 breaths/min.Rectal temperatureis 94oF.There are no focal neurologic
findings.
Laboratoryserum test results at presentation:

Sodium: 112 ntEilL
Potassium:4.0 mEq1L
TSH:35 mIU/L
Arterial blood pH :7.32
Urine microscopic examination shows white blood cells that are too numerous to count and many
gram-negativerods.
The emergencydepartmentphysicians start cautious blood volume support with saline and
initiatefluoroquinolone antibiotic coverage.They intubate the patient endotracheallyand provide
ventilatoryassistance.
Whichone of thefollowing stepsshould you recommendfor the next 72 hours?

A. Levothyroxine, 300 mcg intravenously now and 100 mcg intravenously daily
B. Levothyroxine, 300 mcg intravenously now and 100 mcg intravenously daily; hydrocortisone,
100mg intravenously every 8 hours
C. Triiodothyronine, 60 mcg intravenously now and20 mcg intravenously daily
D. Triiodothyronine, 60 mcg intravenously now and20 mcg intravenously daily; hydrocortisone,
100mg intravenously every 8 hours
E. Levothyroxine, 300 mcg intravenously now and 100 mcg intravenously daily;triiodothyronine,
80 mcg intravenously now
78
Question
A 34-year-oldwoman is admitted to the hospital becauseof a l-year history of frequent headaches,
episodesof confusion, and lack of concentrationwhen she missesa meal. Her symptoms
areimprovedby eating. She was told by a physician that she had prediabetes,and a diet was
prescribed.She discontinuedher diet becauseit did not improve her symptoms. She is taking no
medication.Her family history is remarkable only for the presenceof type 2 diabetesmellitus in
hermother.The patient's weight has been unchangedfor the past year.
Findings from her physical examination are unremarkable.She is 67 inches tall and weighs
140pounds(BMI : 21.9 kglm2).
Laboratorytest results (blood sample collected while fasting):

SerumC-peptide:3.2 nglmL
Seruminsulin:30 pIU/mL
Plasmaglucose:47 mg dL
.
Beforeordering a prolongedfasting study, which one of thefollowing testswould you request
next?
A. Measurementof insulin antibodies
B. C-peptidesuppressiontest
C. Oral glucosetolerancetest
D. Sulfonylureascreen
E. Tolbutamidestimulation test
ffi$Apz$r**AUH$TNCIt{$61
79
Question
{79-year-old woman began treatmentwith alendronate,T0 mg weekly, for osteoporosis,which
had been documentedat both the spine and hip by bone mineral density. Severaldays after
starting the medication, she experiencedintermittent severecramps in her hands und l"gr, u,
well as some tightening in her throat. Discomfort in the chest causedher to go to the emergency
department.
Her medical history includes a total thyroidectomy for a large goiter when she was a
teenager.Medications include levothyroxine, 100 mcg daily, and alendronate,T}mg weekly. She
has experiencedno adversegastrointestinaleffects from the alendronate
On examination, she is afebrile and has a blood pressrueof 120180mm Hg, a respiratory rate
of 20 breaths/min, and a pulse rate of 76 beats/min.Chvostek and Trousseurrrign, ur" pr"r.nt.
Electrocardiographyshows that the erc interval is prolonged to 0.51 seconds.

Calcium:6.5 mgldL
Phosphorus:6.5 mg/dL
Magnesium:2.0 mg/dL
PTH: 25 pglmL
Electrolytes, normal
Serum urea nitrogen: 6 mgldL
TSH:8.3 mIU/L
wich one of thefollowing is the most likely causeof the hypocalcemia?

A. Vitamin D deficiency
B. Hypoparathyroidism
C. Alendronate therapy
D. Inadequatecalcium intake
E. Hypothyroidism
Question
80
You are askedto seea 58-year-old man for advice on medical managementofprimary
aldosteronism.He has a l2-year history of hypertension.He does not use tobacco or alcohol.
He has a parent and a sibling with a history of hypertension.His current medications include a
calcium channel blocker, an ACE inhibitoq a B-adrenergicblocker, and,40mEq of potassium
chloride daily. on physical examination, blood pressureis l2glg2 mm Hg.

Plasmaaldosterone:29 ngldL
Plasmarenin activity: <0.6 nglml per h
Potassium:3.9 mE(L
Sodium :143 mEqlL
Urinary aldosterone:36 pg/24 h (referencerange less than 12 pgl24hwhen urinary sodium
is greaterthan 200 mE(24h)
Urinary sodium :240 mE(24h
CT of the abdomen,with attention to the adrenal glands, does not reveal any adrenal
abnormality. Findings from adrenalvenous sampling show that the patient has equivalent
bilateral aldosteroneexcess.
ESAP2O1O*QUESTNON$
Wich one of thefollowing treatment options
is most appropriate?
A. Continuecurrent pharmacologic program
B. Substituteamiloride for potassium
ctloride
C. Discontinue thepotassiumchlorideandtheACE inhibitor
andsubstitutean angiotensin
receptorblocker
Substitutespironolactone
for potassiumchloride
Performbilateralsubtotallaparoscopic
adrenalectomy
Question
81
A 33-year-oldwoman visits your office

because_ofincreasingpelvic pain during
thelast 6 months' The dysmenorrheawas mensesover
initially wett contr"oi"a'"irt, ibuprofen,
soseverethat she occasionally misseswork but it is now
and has twice visited the emergencydepartment.
Shehasregular menstrualperiods and a
history of normal papanicolaou,rri.ur r".utir.
18years'shewas prescribedoral contraceptives a, ug.
for painful piri"a.. she stoppedtaking oral
contraceptives9 months ago to becomep..gount.
Shebrings you a recent normal pelvic .rlt
urooogruphyreport from an emergencydepartmenl
visit. Her medical historyis notable'for hypothyroidism
and mild asthma.
A pregnancytest result in the office is negative.
on physical examination, she has normal
vital signsand a BMI,o f 22.5 kglm2. Her general
physical and pelvic examinationsare
remarkableonly for discomfort on pelvic-examination.
No discretemassesare identified, and the
pelvic organsare mobile. pelvic nodurarity
and induration are not appreciated.
Whichone of thefollowing steps is best

for this patient?
A' Restartoral contraceptivesusing a
continuous formulation (no placebo intervals)
B. Refer for diagnostjc possibG therapeuticlaparoscopy
1d
c' Prescribeleuprolide depot with estradiol add-backtherapy for l year
D. Prescribeleuprolide depot for 6 months
E. Prescribedanazol
Question
82
432-yearordmanis referredfor evaluation

of dyslipidemia.He haslong-standing HIV infection
andhasbeenreceivinghighly activeantiretroviral
therapyfor the past2rmonths,includinga
nucleosideanaloguereversetranscriptase inhibitor unau prot"ur. int ibiror.He reports
armsandlegsarethinnerandthat his waist that his
circumferen."hu, increaseddespiteweightloss
approximately 3 pounds'He hasnot hadHlV-relatedinr""tioni of
thevirusareundetectable und his circulatingmarkers of
on his currentregimen. .
on physicalexamination, he weighsr77 poundsandis 69 inchestail (BMI :26.1kgmr).
Bloodpressure is 128/82 Hg. ThI patieniis generallystgrrt,lut hasa protuberant
Hehaslossoffat overtheT- lateralu.p""i, ofhis faceanda paucifyofsubcutaneous
abdomen.
limbs'He hasa smalldorsalfat pad anda fat overhis
waist circumferen""oi too cm. Thereis no plethora,
hirsutism,striae,or ecchymoses. proximalmuscreshength
is normal.
Laboratory
testresults:
HDL cholesterol: 35 mg/dl
Totalcholesterol: 390ms/dl
Triglycerides: 1695ms/if
CDocellcount: 578/pl
E$Ap2S1S*QUf;STtONS63
Fastingglucose: 108 mg/dl
Urinary free cortisol :37 pgll4h
The patient begins a diet containing l5%oof calories from fat. After beins on the diet for 3
months, his lipid profile is basically unchanged.
Wich one of thefollowing would you start now?

A. Nicotinic acid
B. Gemfibrozil
C. Atorvastatin
D. Omega-3 fatty acids
E. Rosiglitazone
Question
83
A 52-year-oldman with type 2 diabetesmellitus diagnosedat age45 years returns for routine
reevaluation.He has no concerns.His medications include metformin, 1000 mg twice daily, and
a slow-releaseform of glipizide, 10 mg each morning.
On physical examination, he is mildly obese,is in no acute distress,and has a blood pressure
of 139/88 mm Hg. Findings from the remainder of his physical examination, including retinal
funduscopy,are unremarkable.

HemoglobinAr":6.8%o
Serumcreatinine:0.9 mg/dL
Serumurea nitrogen:8 mg/dl
Urinalysis, grossly negative for protein
Urine albumin to creatinine ratio : 15 pglmg
Wich one of thefollowing statementsabout this patient's blood pressure is correct?

A. The presentblood pressureis adequate
B. The goal for his blood pressureshouldbe 130/80mm Hg or less
C. The goal for his blood pressureshouldbe 120170mm Hg or less
D. The goal for his blood pressureshouldbe 135/85mm Hg or less
E. The goal for his blood pressureshould be 140170mm Hg becauseit is more important to
lower the diastolic pressurethan the systolic pressure
84
Question
Al7-yeat-old adolescentboy presentsfor evaluation of short stature.On the growth chart, his
height has tracked less than the fifth percentile throughout his life, and he has been overweight
for as long as he can remember.He attainedpuberfy at age14 years and was told that he might
have catch-up growth, but this has not happened.He is 64 inches tall, which has been his height
for the past2 years. He has a girlfriend and is sexually active.
He has 2 sistersand 1 brotheq all of whom are very short and have problems with their
weight. His mother is 67 inches tall, and his father is 65 inches tall. He has 2 cousins (paternal
aunt's children) who are also very short. One has a seizuredisorder and the other is mentallv
retardedand did not have teeth until he was 5 years old. They are both obese.
64 H$&p
snrs*SunsTt0tx$
On physicalexamination,blood pressue is 130/70mm Hg, pulse rate is 82 beats/min,
respiratoryrate is l4 breaths/min,and temperatureis 99.2"F.He weighs 190 pounds(BMI:32.6
kglm2).His face appearsround. His pupils are equal and reactive to light and accommodation;
he hasearly cataractsbilaterally. Mucosal membranesare pink and moist, and he has no
macroglossia.His neck is supple with no webbing. Hairline is normal. Thyroid gland is normal
on examination.Lungs are clear to auscultationbilaterally. S, and S, heart soundsare audible,
andhe has no murnurs or rubs. His abdomen is protuberant, soft, and not tender.He has no
hepatosplenomegaly, and bowel soundsare present.On examination of the extremities, he has
no edema,but does have foreshortenedfourth metacarpaland metatarsalbones bilaterally.
Peripheralpulses are2-r bilaterally. On neurologic examination, cranial nerves II-XII are intact,
toneis normal, power 515,and deep tendon reflexes are brisk. He has no striae, rash, skin tags,
or cafdau lait spots.He has 2 to 3 subcutaneoushard nodules on his right thigh and left forearm.
Genitaliaare normal, Tanner stage5.
Electrolytes,within referencerange
Cortisol(AM draw) :181tgldL
FSH: 2.4IUIL
LH:3.3 IU/L
IGF-I : 180 nglml- (normal for age)
Insulinlike growth factor-binding protein 3 :3,0 mglL
Prolactin:15 nglmL
PTH:60 pg/ml
Sexhormone-binding globulin : 30 nmol/L
Total testosterone: 590 ngldL
TSH: 1.9nIUIL
Ionizedcalcium : 5.28 mgldL
Magnesium:2.4 mEq1L
urinary adenosine3',5'-cyclic monophosphate(cAMp), within referencerange
Whichone of thefollowing diagnosesexplains thepatient'sfindings?

A. Constitutionalshort stature
B. Growth hormone deficiency
C. Delayedpuberty
D. McCune-Albright syndrome
E. Pseudopseudohypoparathyroidism
Question
85
A 36-year-oldwoman is referred to you by her primary care physician becauseof an enlarging

goiterand abnormal thyroid function test results. She has had a small goiter for many years with
normalthyroid function. She has.afamily history of thyroid disease,and severalof her siblings
takelevothyroxine.Four months ago, on the advice of a health food storeowneEshe begantaking
kelp tabletsto "help her thyroid." During the last few months, she noted that the goiter at least
doubledin size. She also reports progressively worsening fatigue and a 7-pound weight gain.
On physical examination, she appearswell and her vital signs are normal. Findings from
her generalexamination are unremarkable.Her thyroid gland is diffusely enlargedto about
40 g and is firm, with a clearly palpable pyramidal lobe. No nodules are palpated.There is no
lymphadenopathy, and clinical signs of hypothyroidism are absent.
H$Ap**1S*gUHSTIONS65
Laboratory test results sent by her primary care physician:
SerumTSH: 19.5mIU/L
Wich one of thefollowing would you recommendnow?

A. Begin thyroid hormone replacementwith levothyroxine, 100 mcg daily
B. Stop treatmentwith kelp tablets, measure8 AM cortisol, and measureTSH asain
in 4
months
C. Assessfor thyroperoxidaseantibodies, stop treatmentwith kelp tablets, and measure
serum
TSH again in 2 months
D. Stop treatmentwith kelp tablets and measureTSH again in 2 months
E' Assessfor thyroperoxidaseantibodies, stop treatmentwith kelp tablets, and begin
thyroid
hormone replacementwith levothyroxine at 100 mcg daily
Question
86
{34-year-old woman visited her gynecologist with concernsabout breastdischarge
and
amenorrhea.Her prolactin concentrationwas 350 nglml-. Serum was not
B-hCG detected.The
patient was referred for MRI, which showed a7-mmsellar massthat was adjacent
to, but did not
appearto extend into, the cavernoussinus.You are askedto evaluateher condition.
The patient is otherwise healthy and has an unremarkablemedical history. Findings
from her
physical examination are remarkable only for the presenceof expressible
white breasidischarge
that contains fat droplets under microscopic examination. Pelvisexamination findings
are
normal. Adrenal and thyroid function is normal.
She is treated with a dopamine agonist, has resolution of the breastdischarge,and
resumes
her normal menstrual cycles. Her prolactin level returns to the referencerange.
After 12 months, she moves away. She calls you ayear later to requesta refill of her
dopamine agonist and promises to find a new physician or return to seeyou. Six years
later, she
makes an appointment. She reports that she is generally well and continuesto take
her dopamine
agonist. Her mensesremain normal. She has trouble sleeping and is told she snores.
She also has
arthdtic symptoms in her knees and hips. She statesshe has not noticed any changes
in her hair,
skin, or bowel function. You suspectan additional diagnosis.
Wich one of thefollowing serum measurementswill most likely allow you to diagnose
this
patientb condition?
A. IGF-I
B. ACTH
C. TSH
D. Prolactin
E. o-Subunit of pituitary glycoprotein hormones
Question
87
A 46-year-old woman is referred for evaluation of signs and symptoms consistent

with
Cushing syndrome. Her symptoms include weight gain(43 pound, over 4 years), growth
of a
dorsocervical fat pad, peripheral edema,and proximal muscle weakness.She states
that she has
not had excessfacial hair growth or purple-red stretch marks. Her menstrual cycles
are irregular.
Hypertension was recently diagnosed.She has no history of diabetesor bone fractures.
Her
medications include irbesartan, 150 mg orally daily, and hydrochlorothiazide,I2.5
mgorally
daily.
66 f;sAP2010*QUTSnONS
Physicalexamination reveals a woman who appearsmildly cushingoid. She is 69 inches tall
andweighs226 pounds(BMI : 33.4kglm2).Blood pressureis 160/90mm Hg. Shehas a round,
plethoricface.Dorsocervical and supraclavicularfat pads are present.There is no hirsutism or
striae.Shehas edemaat both ankles. She cannot complete a deep knee bend becauseof muscle
weakness.
Blood
Sodium: l4l mBqlL
Potassium:3.9 mEq1L
Cortisol : 16 pgldL at 8 AM and 16 ytgldLat 4 PM
ACTH : <5.0 pglmL (sameresult when repeated2
days later)
DHEA-S : <12 pgldL
Saliva
Cortisol (midnight) :276 ngldL (referencerange,
<100 ngldl-)
Urine
Cortisol:275 pgl24h
AxialCTimageof theabdomen.
Wich one of thefollowing is the most likely cause of Cushing syndromein this patient?
A. Adrenocorticalcarcinoma
B. Congenitaladrenalhyperplasiawith acquired autonomy
C. Adrenocorticaladenoma
D. Massivemacronodularhyperplasia
E. Primary pigmented nodular adrenocorticaldysplasia
88
Question
A 36-year-oldwoman is referred for evaluation of hypoglycemia. For 10 months, she has had
episodesof somnolence,extreme fatigue, and difficulty being arousedfrom sleep.On several
occasionsshehas been taken to her local emergencydepartmentand has had documentedblood
glucoseconcentrationsof 20 to 30 mgldl-. Symptoms usually appear3 to 4 hours after a meal
andare aggravatedby large meals. Symptoms are always relieved by drinking orangejuice.
Findings from her physical examination are unremarkableexcept for being overweight (BMI
=27.1kglm'z).
A72-hot:r fast is performed during which she sleepsnormally and remains asymptomatic.
Her serumglucose concentrationat the end of the fast is 46 mgldL. There are no sulfonylureas in
herplasmaat either the beginning or the end of the fast, and her serum does not contain insulin
antibodies.Pancreaticultrasonography,spiral CT ofthe pancreas,and celiac axis arteriography
showno abnormality.During a spontaneousepisodeof hypoglycemia occurring2 and a half
hoursafter a meal, the following laboratory values are observed:serum glucose, 38 mg/dl;
plasmainsulin, 10.4 pIUlmL; C-peptide,3.1 nglmL; and proinsulin,20 pmol/L.
Whichone of thefollowing is the most reasonablenext step?

A. Perform exploratory surgerywith intraoperativeultrasonographyof the pancreas
B. Measureinsulin levels in the right hepatic vein after infusion of calcium into the splenic,
superiormesenteric,and gastroduodenalarteries
C. Prescribediazoxide
D. Prescribeoctreotide
E. Order another 72-how fast
3010-SUHSTI0NS67
H$,Ap
89
Question
the vertex'
A2l-year-old man is evaluatedfor hair loss. He has noted this at both temples and
hair
There is no mechanical reasonfor him to be losing hair. He does not have concurrent
13 years and its growth steadily
loss elsewhereon his body. Pubic hair was flrst noted at age
lower
increaseduntil age 18. Similarly, there has been increasinghair growth on the abdomen,
patient has been healthy
back, legs, and upper lip. He reachedadult height at age 17 years'The
and does not take anYmedications.
There is no
Both his father and paternal grandfatherexperiencedbalding by age 25 yeats'
family history of autoimmune diseases.
: kglm'z)'
on physical examination, he is 64 inches tall and weighs 145 pounds (BMI 24'9
elsewhere.Examination of his
There is thinning of the hair at the temples and vertex, but not
skin changes'
scalp reveals no evidence of erythema or inflammation. He has no acne or other
massesare noted'
His pubic hair and phallus are normal, and his testesare 25 mLbilaterally. No
which one of thefollowing is the most appropriate next step in the evaluation?
A. Skin biopsy of the scalP
B. Measurementof circulating androgens(testosteroneand dihydrotestosterone)
C. Measurementof 24-hour urinary ketosteroids
D. KaryofypeanalYsis
E. No further evaluation is needed
90
Question
level and is
A62-year-oLdman is noted to have an isolated elevated serum alkaline phosphatase
for hypertension
refenld to your clinic for further evaluation. His medical history is remarkable
by an esophageal stricture' A bone
and severegastroesophagealreflux previously complicated
the entire right
scanreveals intenseuptake in the skull, the first and third lumbar vertebrae,
the
hemipelvis, and the pioximal two-thirds of the right tibia. X-rays of these areasconfirm
or bone metastases'
diagnosisof Pagetdisease;there is no radiographic evidenceof malignancy
Heieports no bone pain, bone deformiry joint pain, headache,hearing loss, muscle weakness'or
previous fractures.His only medications are lisinopril and omeprazole.
no tibia
On physical examination, his appearanceis normal with no skull enlargementand
examinations are also normal' The
deformity. Findings from hearing, neurologic, and prostate
all well healed' He
pharynx is ,.*urkubl" for the sites of previous tooth extractions,which are
weighs i76 pounds(BMI : 24.5 kglm2).

Alkaline phosphatase: 586 U/L
25-Hydroxyvitamin.D: 38 ng/ml
Intact PTH :32 PglmL
Prostate-specific antigen: L.9 nglmL
Albumin :4.1 gldL
Calcium:9.5 mgldL
:
cross-linkedNtelopeptide of type 1 collagen 119 nmol/mmol creatinine
68 s**?#ffi$Tl#ruS
*s&p*{3'*
llhich one of thefollowing is the best managementplan?
A. Prescribea 6-month course of daily oral alendronate
B' Prescribedaily subcutaneousinjections of salmon calcitonin
c. Administer a single intravenousdose of pamidronate or zoledronic acid
D. Prescribedaily subcutaneousinjections of teriparatide
E. Perform a biopsy of the right iliac bone
Question
91
{27-yeat-old patient with Graves diseasee-mails you when she finds a2009 US Food and Drug
Administration warning posted on the Internet about the toxic effects of propylthiouracil (pTU)
usein patientswith Graves disease.You have been treating the patient with ptU, 100 mg 3
times daily by mouth, for the past 4 months. She is clinically euthyroid and has mild endocrine
ophthalmopathy.Her serum TSH concentration4 weeks ago was detectable at0.40 mIU/L.
Wich one of thefollowing actions should you choose?

A. Discontinue PTU and administer ablative radioiodine
B. Substitutesaturatedsolution of potassium iodide for pTU
C. Take no action and advise the patient that the Food and DrugAdministration warning is
basedon a small number of patients
D. ReducePTU dosageto 50 mg by mouth twice daily
E. Regularly monitor serum liver function and discontinue PTU if test results are abnormal
Question92
427-year'old man presentsfor evaluation of type I diabetesmellitus of 12 years, duration. He

would like to reevaluatehis approachto diabetescare and is anxious to do all he can to prevent
diabetescomplications. He is particularly concernedabout the potential for kidney diseasesince
an acquaintancerecently starteddialysis, pending kidney transplantation.
He has no other medical problems. He eats a healthy, balanceddiet that is low in fat. Since
age2l years, he has maintained good glucose control with hemoglobin A," values generally less
than7.IYo.Medications include insulin glargine once in the morning and insulin aspartbefore
eachmeal.
Blood pressureis 121176mm Hg, and pulse rate is 65 beats/min.He is 71 inchestall and
weighs175pounds(BMI: 24.4kgm2). Physicalexaminationfindings are normal. Dilated eye
examinationshows no evidenceof retinopathy.
Potassium: 4.4 mEq1L
Sodium:142mE(L
LDL cholesterol : 98 mgldl
HemoglobinAr":6.7%o
Albumin to creatinineratio: 19 trtglmg
H$Ap2S1S*QUF$T!O|\I$69
Wich one of thefollowing best addresseshis concerns about potential developmentof kidney
disease?
A. Refer to a diabetesdietitian for instruction on a low-protein diet
B. PrescribeanACE inhibitor
C. Prescribean angiotensin-receptorblocker
D. Reassurehim and recommend ayearly microalbumin test and persistencein glucose control
E. Prescribea nondihydropyridine calcium channel blocker
Question
93
A l3-year-old adolescentgirl comes to your office becauseher mother is concernedabout heavy
periods; she has been referred for evaluation of possible polycystic ovary syndrome. She had
menarche6 months ago and has had 5 periods. The patient saysthat her periods are stressful
becauseshe is not able to wait longer than t hour betweenpad changes.She reports her periods
last 8 to 9 days. Her mother has allowed her to stay home from school 5 days to deal with the
bleeding, and the patient admits to skipping school on several occasionsto avoid this dilemma.
She has seenher pediatrician 3 times in 6 months, has had blood work done, and has been
encouragedto take iron supplementation.She reports no shortnessof breath, dizziness,or chest
pain, but does feel tired more often now. Her mother thinks she has gained abotil2} pounds over
the past year.
The patient has no medical problems and has never had surgery.She recalls going through
puberty about the sametime as her friends. She has never been sexually active. She does not
take any prescription, herbal, or over-the-countermedicines except for the iron prescribedby
her pediatrician. She is well adjusted,performs well in school, and has a good social network.
She does not drink alcohol, smoke cigarettes,or do any drugs. Her family history is notable
for hypertensionand Wpe2 diabetesmellitus in her mother and hypercholesterolemiain her
father. Her mother reports that her own periods were always heavy, but never like this. She had a
hysterectomy 5 years ago becauseof fibroids. There is no known bleeding disorder in the family.
The patient recalls 1 "bad nosebleed" last year after getting hit by a soccerball.
On examination, vital signs are normal. She is 64 inches tall and weighs 137 pounds (BMI
:23.5 kgkf). She has pale conjunctiva. Acne is presenton her foreheadand chin. She has no
thyromegaly, lymphadenopathy,hirsutism, rash, or bruises.Breast and escutcheonare Tanner
stage5. There are normal findings on abdominal examination. Examination of her external
genitalia reveals no active bleeding, intact hymen, and normal anatomy for her age. She refusesa
bimanual examination. Ultrasonography from her pediatrician shows a normal uterus and 2 cysts
in her right ovary. Both are describedas simple cysts (1.7 cm and 0.6 cm).
Laboratory test results from the referring physician:

Hemoglobin:8.6 gldL
Hematocrit:25.7%
Plateletcount: 326 x l}3lltL
TSH:2.4nIU/L
B-hcc: <3 IU/L
Prothrombin time, normal
Activated partial thromboplastin time, normal
Which one of thefollowing is the most appropriate next step in her evaluation?
A. Transcervical sonohydrohysterogram
B. Von Willebrand panel
C. Progesteronechallenge
D. Dexamethasonesuppressiontest
E. Factor V Leiden testins
70 ESAP2O1O-QUESTIONS
94
Question
A 56-year-oldmanpresentswith an 8-yearhistoryof hypertension.His currentantihypertensive

medicationsincludeamlodipine,10mg daily;clonidine,0.lmg twice daily;terazosin,4 mg once
KCl,20 mEqtwicedaily.His serumsodiumconcentration
daily;and is 145mBqlL,andhis serum
potassium
concentration is 3.4mEq/L.
Thereis no family historyof hypertension.
He is keento considera surgicalprocedureif it
wouldcorrecthis hypokalemiaandimprovehis hypertension control.
On physical examination,blood pressureis 160194 mm Hg, heartrateis 86 beats/min,
andBMI is 42.6kglrrf. His excessbodyweightis symmetrically distributed.Findingsfrom
examinationsof the heartandabdomenarenonnal,andperipheralpulsesareintact.
Plasma
Aldosterone:32 ngldL
Plasmarenin activity : <0.6 nglml- per h
Urine
Urinary aldosteroneexcretion on a high-sodium
diet:36 pgl24h (urinarysodium:2aa mE(24h)
Axial CT imageof the abdomen,showing a left

adrenalnodule(arcow).
Adrenal venous sampling is performed during cosyntropin infusion, 50 mcg/h.
Measurement RightAdrenal Vein Inferior Vena Cava LeftAdrenal Vein

Aldosterone, ngldL 38 88 1240
Cortisol, mgldL 26 24 730
Wich one of thefollowing is the best next step in management?

A. Perform laparoscopicleft adrenalectomy
B. Perform a secondadrenalvenous sampling for aldosteroneand cortisol
C. Perform6B-'3'I-iodomethyl-19-norcholesterol(NP-59) scintigraphy
D. Measureserum l8-hydroxycorticosterone
E. Perform laparoscopicright adrenalectomy
Question
95
A52-year-oldmanwith a 6-yearhistoryof type 2 diabetesmellituspresentswith concernsabout

hisrisk for cardiacdisease.He is generallywell andhasno specificmedicalconcerns.He hasno
historyof hypertension.He hasnot experienced angina,a reductionin exercisecapacity,dyspnea
on exertion,or peripheraledema.He doesnot smokecigarettes.Medicationsincludemetformin,
glipizide,aspirin,andhydrochlorothiazide. He hasa family historyof diabetes,andalthoughhe is
unawareof anyheartdiseasein his relatives,his motherdiedsuddenlyat age63 years.
H$Ap3010*QUESTToN$71
from the remainder of
BMI is 34kglrrf ,and blood pressureis 122'3 mm Hg. Findings
over the last year show
the examination are unremarkabG.Records of laboratory evaluations
profile from 1 year earlier shows the
hemoglobin A," values of 7 .0o/o,7 .3o/o,and7 .t%. Alipid
mgldL; HDL cholesterol,4T mgldL1'
following: total cholesterol, 166 mgldL;triglycerides, 157
and LDL cholesterol, 89 mg/dl.
Current laboratory test results:

Hemoglobin Ar":7.2%6
Triglycerides : 178 mg/dl
LDL cholesterol : 82 mgldL
Albumin to creatinineratio: 13 V{mg
interventionfor this patient?

Wich one of thefollowing medications is the most appropriate
A. Exenatide
B. Fenofibrate
C. Simvastatin
D. Niacin
E. Pioglitazone
Question96
diabetesmellitus, and
A 68-year-old man with a history of long-standing hypertension,
After appropriateantibiotic
hemodialysis is admitted to the hospitallor tfeatment of sepsis'
to seehim becauseof elevatedserum
treatment is initiated, the endocrinology team is asked
PTH (517 pglmL)' The serum
concentrationsof phosphorus(5.9 mg/dl) and serum intact
D concentrationis 21 nglmL'
calcium concentrationis 8.6 mg/dl, and the 25-hydroxyvitamin
to lower his serum intact PTH

Wich one of thefollowing is the most reasonabletreatment
level?
A. Start cinacalcet
B. Administer calcium supplements
C. Administer PhosPhatebinders
D. Perform ParathYroidectomY
E. Begin ergocalciferol,50,000IU onceweekly
97
Question
muscle cramps that were first
A 36-year-old woman presentswith fatigue, constipation, and
vague abdominal pain' Menstrual
noted 6 months ago. During the past 2 months, she has had
4 months before this visit'
periods had been regular, occurring at month$ intervals, but stopped
She has no children.
and heart rate is tegtlar at76
on physical examination, blood pressureis 100/70 mm Hg
of the neck, lungs' and heart
beats/min.Her complexion is sallow. Findings from examination
are hypoactive, and a delay in
are unremarkable.The abdomenis normal. Deep tendon reflexes
the relaxation Phaseis noted.
72 H$Ap20{$*Q{JFSTISN$
Serumtotal cholesterol: 147 mgldL
Hematocrit:32%o, with normocytic,normochromicindices
Hemoglobin:8.9 gldL
SerumTSH:6.0 mIU/L
SerumfreeTo:0.3 ngldl-
SerumhCG, negative
Serumglucose: 62 mgldL
Wich one of thefollowing shouldyou recommendnow?

A. Treatwith levothyroxine,100 mcg daily
B. Treat with levothyroxine, 100 mcg daily, and cortisone acetate,30mg daily
C. Measure8 AM plasmacortisol andACTH
D. Measureadrenal autoantibodiesand thyroperoxidaseantibodies
E. Measureserum T, concentration
98
Question
A52-year-old man with type 2 diabetesmellitus diagnosedat age45 years returns for a routine
follow-up visit. He has no symptoms now. His medications include metformin, 500 mg twice
daily, and a slow-releaseform of glipizide, 10 mg daily taken in the morning.
On physical examination,he is mildly obese(BMI : 30.5 kg/m'z),and blood pressureis
139i88mm Hg. Findings from the remainderof his physical examination,including retinal
funduscopy,are unremarkable.
HDL cholesterol : 40 mgldL
Urinary albumin to creatinine ratio: 22 pglmg
Fastingglucose: 164 mgldL
Serumurea nitrogen: 8 mg/dl
Whichone of thefollowing therapeutic alterations would you recommendto improve glycemic

control?
A. Increasethe glipizide dosageto 20 mg daily
B. Initiate a low-carbohydrate,high-protein diet
C. Add a thiazolidinedione
D. Substitutesitagliptin, 100 mg daily, for the glipizide
E. Increasethe metformin dosageto 2000 mg daily
99
Question
A67-year-old man is self-referredbecausehe believes he may have an overactive thyroid

gland.He has 2 sisterswith Gravesdiseasewho have symptomssimilar to thosehe recently
experienced.During the past 6 months,he has lost 15 poundsdespitea good appetite.He has
ffi$&g3x{}1{}**u*$T!#MS
73
felt overly warm for severalmonths and has perspired excessively.He noted palpitations about a
week before his visit to you and believes that his heart rate is irregular.
On physical examination, blood pressureis 150/82 mm Hg and pulse rate is 110 beats/min
and irregular. He has bilateral lid lag and widening of the palpebral fissure, but no proptosis. His
thyroid gland is diffirsely enlargedto twice normal size. The lung fields are clear to auscultation.
Heart examination reveals an irregular rate and a prominent secondcardiac sound (Sr) in the
pulmonic area.There is no murmur.

SerumTSH: <0.01 mIU/L
SerumfreeTo :3.2ngldL
Electrocardiogramshows atrial fibrillation without ST:segmentor Tlwave abnormalities.
In addition to prescribing a B-adrenergic blocking agent and methimazole,which one of the

following should you recommend?
A. Referral for cardioversion if atrial fibrillation persistswhen euthyroidism is achieved
B. Warfarin administration; referral for cardioversion if atrial fibrillation persists6 weeks
after euthyroidism is achieved
C. Warfarin administration; referral for cardioversion if atrial fibrillation persists3 to 4
months after euthwoidism is achieved
D. Aspirin, 325mg twice daily by mouth
E. Referralfor cardioversionif atrialfibrillation persists3 to 4 monthsaftereuthyroidismis
achieved
Question100
A 5l-year-oldmanis referredby his primarycarephysicianfor management of his lipids.

Thepatientreportsgenerallygoodhealthandis not takingregularmedications. Thereis no
historyof diabetes,hypertension, vasculardisease,or cigarettesmoking.He reportsno family
historyof cardiacdiseaseor diabetes.He hasfolloweda caloricallyrestricteddiet,which
i weightlossof
includeslimits of saturatedfat andcholesterol,for severalyearsaftersuccessful
6 to 8 pounds.He exercises45 to 60 minutes3 timesweeklyanddrinks5 alcohol-containing
i beverages a week.Lipid profilesfrom theprevious2 yearsareshown:
I
j
LI
I
Lipid Last Year This Year
il
i1
1i
Total cholesterol,mg/dl 264 258
li Triglycerides, mg/dl 110 105
HDL cholesterol,mg/dl 67 70
li r67
I1 LDL cholesterol,mgldL 174
il
I His primarycarephysicianfecommended startingan HMG-CoAreductase inhibitorbasedon his
II sex,age,andconsistentlyelevatedLDL cholesteroldespiteappropriatelifestylemeasures. The
l patientis reluctantto startmedications.
,l
On physicalexamination,bloodpressureis 120174 mm Hg, andhe weighs195pounds(BMI
I :26kglm'z). Findingsareotherwiseunremarkable. Laboratorytestingrevealsthe following
l values:fasting glucose, g2mgldL; TSH, 1.3nIUIL; andserumcreatinine, I.4 mgldL.
li
j,
Il
i1
jr1
lii
ru
il1
ls
lli l
74 ESAP201o-QUESTTONS
Wich oneof thefollowingwouldprovidethebestmeasureof his cardiacrisk?
A. Measurement of apolipoproteinB andapolipoproteinAl
B. Measurement of apolipoprotein(a)
C. LDL phenotypingby nuclearmagneticresonance
D. Exercisestresstest
E. CT scanfor coronaryarterycalcification
Question101
{32-year-old man with a l4-year history of type I diabetesmellitus comes to your office with
concernsabout an increasedfrequency of hypoglycemia. Insulin pump therapy was started
3 monthspreviously. He decided to initiate pump therapy becauseof his increasedneed for
flexibility in his scheduleand an increasing frequency oitrypogtycemia. Before pump therapy,
his hemoglobinA," level was 6.4%o,andhe took insulin glargine once daily with meal-time
insulin lispro. Since starting the pump, his hypoglycemia has not decreasedas he had hoped. For
example,he experienceda severehypoglycemic episoderequiring glucagon (administeredby his
wife) a week before this appointment.Interestingly, that particular hypoglycemic episode,similar
to severalothers, occurred less than t hour after a large meal that included steak, salad,and ice
cream.There has been no changein his hemoglobin A," level, but he has gained 5.5 pounds since
starting pump therapy. BMI is 26 kg/rn-r.
His basal rate for his pump with insulin lispro is 1.0 units/h and meal-time boluses are 1 unit
per 15 g ofcarbohydrate.
Wich one of thefollowing is the best recommendation?

A. Extend the bolus over 2 hours for high-fat meals
B. Decreasehis insulin to carbohydrateratio for high-fat meals
C. Add pramlintide before meals, up to 60 mcg per dose,as tolerated
D. Extend the bolus over 15 minutes
E. Prescribea continuous glucose monitor
102
Question
A 35-year-oldmanpresentsto your clinic for furtherevaluationof rickets.He is accompanied

by his parentswho confirmthatprobablehereditaryricketswasdiagnosedat age4 yearsand
wasinitially treatedwith phosphateandcalcitriol.Thepatientis adopted,andfamily historyis
not available.In addition,he hasnot beencaredfor by an endocrinologist for manyyears.The
patient'sprimaryconcernat this time is relatedto skeletaldeformityandassociated pain.He
hasbeenevaluatedby an orthopedicsurgeonfor consideration of correctivesqrgery.However,
the surgeonis concernedabouthis laboratorytestabnormalities andseeksyour opinion
regardingfuturetreatment.The patientis currentlytakingpotassiumphosphatesupplements and
hydrochlorothiazide.
Calcium:11.0mgldL
Albumin:3.4 gldL
Serumureanitrogen:37 mgldL
Creatinine:L7 mg/dL
Phosphorus:4.7mgldL
Alkalinephosphatase : 1599UlL
75
HSAP201O-QI.JESTIONS
PTH: 4800 pglml-
25-HydroxyvitaminD: l8 nglmL
1,25-Dihydroxyvitamin D, : 27 pglml-
Wich one of thefollowing treatmentsis indicated to remedy this patient's hypercalcemia?

A. Dipyridamole
B. Calcitriol
C. Ergocalciferol
D. Zoledronic acid
E. Subtotal parathyroidectomy
103
Question
A24-year-old woman with chronic schizophreniais referred for evaluation of abnormal results
from thyroid function tests after experiencing an acute exacerbationof psychosis. She has no
history of thyroid dysfunction, but severalfamily membershave been affected by autoimmune
thyroid disease.Over the preceding 3 months, she has lost 17 pounds and has noted insomnia,
tachycardia,heat intolerance,and irregular menses.
Physical examination shows an anxious and restlessyoung woman with resting tachycardia
(pulse rate,120 beats/min); tremor of extendedfingers; bilateral lid lag and "stare"; warm, moist
skin; brisk reflexes; and an impalpable thyroid gland.
Thyroid function test results:

Thyroglobulin : 1.0 nglmL
TSH: <0.01mIUIL
Free T, : 4.2 ngldl-
24-hotr radioiodine uptake: 2%o

A. Hyperthyroxinemia from estrogeningestion
B. Factitious hyperthyroidism
C. Struma ovarii
D. Euthyroid hyperthyroxinemia secondaryto acutepsychosis
E. Amphetamine abuse
104
Question
A42-year-old man presentsto the emergencydepartmentwith the suddenonset of double vision,

ptosis, and a headache-the worst of his life. Recent MRI documenteda 1.6-cm pituitary tumor,
which did not abut the optic chiasm. The tumor was originally discoveredon CT performed after
a motor vehicle crash severalyearb earlier. It had remained stable in size. The patient's only
hormone abnormality is a low testosteroneconcentration;his LH and FSH levels are normal. On
physical examination, he has right-sided third nerve palsy. He is otherwise healthy. He statesthat
he is using testosteronegel.
CT performed emergently reveals a bright signal in the area of the pituitary gland consistent
with hemorrhage;he appearsto have pituitary apoplexy. He undergoesemergencysurgical
decompression.His visual fields are full after the operation,but he still has a third nerve palsy.
His postoperativecourseis otherwise uneventful. He is dischargedon hydrocortisone, 37.5 mg
daily, and he continueshis testosteronetherapy.
76 H$Ap2S10*&rif;$Tr0hr$
He is subsequentlyreferred to you for ongoing care.You question whether he has underlying
secondaryadrenal insufficiency and whether you should wean him offhydrocortisone
therapycompletely. Becauseyou consider the hydrocortisone dosage(37.5 mg daily) to be
supraphysiologic,you decide to gradually lower his dosageto a total of 15 mg daily. You ask him
to return to your office in 4 weeks.
Wich one of thefollowing would be most helpful in deciding whether he haspermanent or

reversible secondary adrenal insfficiency?
A. Measure 24-hovr urinary free cortisol after he skips the previous evening's dose of cortisone
B. Perform a cosyntropin stimulation test (250 mcg intravenously)
C. Perform an insulin tolerance test
D. Measureprolactin and free To
E. MeasureACTH
Question
105
A 65-year-oldman is being followed up for Epe 2 diabetesmellitus of severalyears' duration.

His condition is treatedwith a combination of metformin, 1000 mg twice daily, and glimepiride,
4 mg daily. He has background retinopathy and microalbuminuria. Over the last 3 months, he
hasdevelopeda nonhealing plantar ulcer over the first metatarsophalangeal joint. The ulcer
hasa clean baseand extensivecallus at its margins. Further examination reveals a sitting blood
pressureof 120160mm Hg with no significant changein responseto standing.His heart rate does
not changein responseto the Valsalva maneuver.Other than a BMI of 32.5 kdm,, the rest of the
patient'sexamination findings are unremarkable.
Hemoglobin:12.5 gldL
MCV:85 pm3
White blood cell count :560011tL
Platelets: 150 x l03l1tL
Alkaline phosphatase: l45UI-
Alanine aminotransferase: 75 U lL
Fastingblood glucose: 175 mg/dl
HemoglobinA," : 8.00lo
Total cholesterol : 240 mfldL
Yourdiscussionabout alternative therapiesturns to the use of exenatidein combina(ion with his

existingmedications.
Wich one of thefollowing statementsregarding exenatidetherapy in this patient would be

correct?
A. It may unmask existing gastroparesis,resulting in nauseaand vomiting
B. It will not causehypoglycemia in combination with the patient's current therapy
C. It producessignificant and sustainedweight loss by increasing energy expenditure
D. It is expectedto lower hemoglobinA," by approximately1.0%
E. It carriesa higher risk of pancreatitisthan other therapies
E$AF?01$*Qr.|HgTlON$
77
Question106
A32-year-oldwomanis referredfor evaluationof an incidentallydiscoveredleft adrenal

mass.CT of the abdomenwasperformedafterreportedabdominalpain,which waseventually
attributedto irritablebowel svndrome.CT showeda 1.5-cmleft adrenalnodulewith a densiWof
3.5 Hounsfieldunits.
Her weighthasbeenstable,andmenstrualcycles
arenormal.Hypertensionwasdiagnosed3 yearsago.
Shehasno historyofdiabetesor bonefracturesand
hasno family historyof hypertension.
Medicationsincludeamlodipine,10mg orally
daily,andlisinopril,20 mg orally daily.
Physicalexaminationrevealsa womanwho is
symmetricallyobese.Sheis 64 inchestall andweighs
182pounds(BMI: 3l.2kglm'z).Bloodpressure
is 144/82mm Hg. Thereis no hirsutism,striae,or
edema.Findingsfrom heartandlung examinations
arenormal.
Axial CT image of the abdomen.
Bloodtests(4 PM blooddraw):
Sodium:143 nEqL
Potassium:3.6mEqil
Plasmafractionatedmetanephrines, within referencerange
Plasmaaldosterone :6.9 ngldL
Plasmareninactivity <0.6nglml- per h
Cortisolafterovernightl-mg dexamethasone test: 1.1pg/dl

suppression
Whichoneof thefollowing is the bestnextstepin thispatient'scare?

A. Obtaina midnightsalivarycortisolmeasurement
B. Remeasure aldosterone andreninlevelsin themorning
C. Obtain 24-hoururinary fractionatedmetanephrineand catecholaminemeasurements
D. PerformadrenalMRI with chemicalshift imaging
E. No additionaltestingnow,performfollow-upCT in 3 to 6 months
Question107
You are askedto seea 39-year-old man with painful bilateral gynecomastia.Over the past 4
months, he has noticed discomfort under both areola and, more recently, a swelling in both
breasts.It has worsenedto the point that he has notable discomfort with any pressureto his chest
wall.
He has a complex medical history. Eight years earlier, during an evaluation for headaches,he
was documentedto have mild idiopathic h1'perprolactinemia,which has not been treated.At that
time, MRI of the pituitary gland showed no evidenceof a tumor. He also has a recent 4-month
history of hepatitis causedby the hepatitis C virus. At the time of that diagnosis,he developed
78 ESAP201O-QUESTIONS
malaiseand jaundice, which have improved over time. He has hypertensionthat is treatedwith a
combinationof spironolactone,50 mg twice daily, and hydrochlorothiazide.
Review of systemsis notable for a l0-pound weight loss in the past 6 months, frequent loose
stools,palpitations, and heat intolerance.
On physical examination, he appearsnervous. Blood pressureis 130/86 mm Hg, and
heartrateis 88 beats/min.He is 70 inches tall andweighs 170 pounds (BMJ : Z+.1-t1gmt;.
Examinationof the head, eyes,ears,nose, and throat documentsa difflsely enlargedihyroid
glandthatis nontender.Aside from tachycardia,findings from cardiac,pulmonary and
abdominalexaminationsare nonnal. On examination of his chest well, you note palpable
subareolartissue bilaterally that is tender.In addition, he has a slight resting tremor in both
hands.There is no evidence of ascites,lower extremity edema,or spider angiomata.Findings
from his skin examination are normal without palmar erythema.
TSH:0.01 mIU/L
FreeTo:2.0 ngldL
Estradiol:62 pglmL
B-hCG,undetectable(quantitative assay)
LH:4.6\U/L
Prolactin:40 nglmL
Totaltestosterone: 429 nglmL
Wich one of thefollowing is the mostplausible explanationfor this patient's gtnecomastia?

A. Hyperthyroidism causing a decreasein sex hormone-binding globulin level
B. Hyperprolactinemiain combination with athiazide diuretic
C. Spironolactonecompeting with estradiol binding to sex hormone-binding globulin
D. Hepatitisresulting in hepatic production of a steroid with estrogenicactions
E. Hepaticdysfunction leading to increasedandrogenclearance
108
Question
Youareaskedto seea 64-year-oldwoman after her primary care physician documenteda serum
TSHconcenhationof 0.1 mIU/L and informed her that she had subclinical hyperthyroidism.
Shehasa history of mitral valve prolapse and wrist fracture after a fall last year. Otherwise, she
acknowledges no medical problems.
On physical examination, she is a tall, thin woman (BMI : 17 kglmr) with normal vital
signs.Shehas no ophthalmopathy,and her thyroid gland is impalpable. There is no tremor or
hypeneflexia.
wich one of thefollowing conclusionsdo you draw as thepractitioner?

A. Progressionto overt hyperthyroidism is rare, and annual endocrine follow-up is sufficient
B. A singlemeasurementof low or suppressedserum TSH in an otherwise asymptomatic
patientis ofno concern
C' In contrastto overt hyperthyroidism, subclinical hyperthyroidism does not decreasebone
mass
D. Shehas an increasedrisk of all-causemortality, but a particularly increasedrisk of
cardiovascularmortality
E. Prospectiveinterventional trials have validated therapeuticintervention in subclinical
hyperthyroidism
ESAP2010*QUEST|ON$79
Question109
A 55-year-old man with a 2}-year history of type 2 diabetesmellitus presentswith a chief

concern of blurring of both near and distant vision that has worsened over the last few weeks.
In the past, his diabeteshad been treated with oral medications,but his prescriptions expired 5
years ago and he has not had them refilled. Other than occasionalover-the-countermedications
for headachesand cold symptoms,he has not taken any medication.
On physical examination, blood pressureis 165/96 mmHg, and heart rate is 92 beats/min.
Retinal examination shows bilateral hemorrhagesand new vessel formation near both optic
discs. Bilateral carotid bruits are noted, but his foot pulses are all presentand easily felt. There is
no plantar sensation,and ankle reflexes are absent.

HemoglobinAr":1I.5Yo
Fastingglucose:275 mgldL
Potassium:5.5 mEq/L
LDL cholesterol: 190 me/dl-
In addition to urgent reiferral to an ophthalmologist, which of thefollowing would you implement

first to preserve his vision?
A. ACE inhibitor at half-maximum dosage
B. B-Adrenergicblocker and a loop diuretic
C. Aspirin
D. Basal-bolus insulin to quickly lower his hemoglobin A," level to 7%o
E. Statin to reduce LDl-cholesterol concentrationto less than 100 ms/dl
110
Question
A32-year-old woman presentsrequestingcontraception.She is gravida 4, para 1, and she had a

deep venous thrombosis immediately following the term cesareandelivery of a daughter I year
ago. She continues to breastfeedher infant, but only twice daily. The child is in good health. The
patient had 3 spontaneousmiscarriagesbefore the term pregnancy.Findings from the evaluation
after the third miscaniage were unremarkable except for detectableTPO antibodies. The
patient's karyotype is 46,XX.
Her family history is unknown becauseshe was adopted.Her review of systemsis
completely normal except for mild fatigue and allergic rhinitis. She does not smqke. Her menses
resumed about 6 months ago andhave been regular.During intercourse,her husbanduses
condoms. Since frequency of sex is less than before the birth of their child, this method has been
relatively acceptableto both of them until recently. They would like to have another child, but
not in the next year.
On physical examination, she appearswell, and BMI is 23 kglm2. Blood pressureis
ll5l75 mm Hg. There are no abnormal skin findings. Her thyroid gland is of normal size and
consistencywithout nodules or tendemess.Findings from the rest of the physical examination,
including those of the breast and pelvic examinations,are nonnal. Laboratory test results include
the following values: TSH, 2.0 nIUIL; free To, mid-referencerange; TPO antibodies,detectable;
and antinuclear antibodies, detectable.A postpartum evaluation for thrombophilias was normal
except for heterozygosity for the factor V Leiden allele.
80 n$Ap?01s*&ut$Tt0F*s
Question109
A 55-year-old man with a 20-year history of type 2 diabetesmellitus presentswith a chief

concern of bluning of both near and distant vision that has worsened over the last few weeks.
In the past, his diabeteshad been treatedwith oral medications,but his prescriptions expired 5
years ago and he has not had them refilled. Other than occasionalover-the-countermedications
for headachesand cold symptoms,he has not taken any medication.
On physical examination, blood pressureis 165196mmHg, and heart rate is 92beatslmin.
Retinal examination shows bilateral hemorrhagesand new vessel formation near both optic
discs. Bilateral carotid bruits are noted, but his foot pulses are all presentand easily felt. There is
no plantar sensation,and ankle reflexes are absent.

Hemoglobin Ar": l1.5Yo
Fastingglucose:275 mgldL
Potassium:5.5 mEq/L
LDL cholesterol: 190 ms/dl
In addition to urgent referral to an ophthalmologist, which of thefollowing would you implement

first to preserve his vision?
A. ACE inhibitor at half-maximum dosage
B. B-Adrenergicblocker and a loop diuretic
C. Aspirin
D. Basal-bolusinsulin to quickly lower his hemoglobinA," level to 7o/o
E. Statin to reduce LDl-cholesterol concentrationto less than 100 ms/dl
110
Question
43Z-year-old woman presentsrequestingcontraception.She is gravida 4, para I, and she had a

deep venous thrombosis immediately following the term cesareandelivery of a daughter l year
ago. She continuesto breastfeedher infant, but only twice daily. The child is in good health. The
patient had 3 spontaneousmiscarriagesbefore the term pregnancy.Findings from the evaluation
after the third miscarriagewere unremarkableexcept for detectableTPO antibodies.The
patient's karyotype is 46,XX.
Her family history is unknown becauseshe was adopted.Her review of systemsis
completely normal except for mild fatigue and allergic rhinitis. She does not smqke. Her menses
resumedabout 6 months ago and have been regular. During intercourse,her husbanduses
condoms. Since frequency of sex is less than before the birth of their child, this method has been
relatively acceptableto both of them until recently. They would like to have another child, but
not in the next year.
On physical examination, she appearswell, and BMI is23kglm2. Blood pressureis
ll5l75 mm Hg. There are no abnormal skin findings. Her thyroid gland is of normal size and
consistencywithout nodules or tendemess.Findings from the rest of the physical examination,
including those of the breastand pelvic examinations,are nornal. Laboratory test results include
the following values: TSH, 2.0 nIUL; free To, mid-referencerange; TPO antibodies,detectable;
and antinuclear antibodies, detectable.A postpartum evaluation for thrombophilias was normal
except for heterozygosity for the factor V Leiden allele.
80 E$Ap201$*&[JFST|*!*S
Assumingthat all are socially acceptable to thepatient, which one of thefollowing birth control
methodswould be bestfor her medically?
A. An intrauterine system (device) containing copper
B. A contraceptivepatch containing ethinyl estradiol and a synthetic progestin
C. A standardoral contraceptivecontaining 30 mcg of ethinyl estradiol and a synthetic progestin
in eachpill with instructionsto take 1 pill daily for 84 days followed by a 6-day pill-free
interval
D. A standardoral contraceptivecontaining 20 mcg of ethinyl estradiol and a synthetic progestin
in eachpill with instructionsto take 1 activepill daily for 21 days and then a placebopill for
7 days
E. A standardoral contraceptivecontaining 20 mcg of ethinyl estradiol and a synthetic progestin
in eachpill with instructions to take 1 pill daily without breaks
111
Question
While taking estrogentherapy,a 55-year-oldpostmenopausal woman had osteopeniadocumented

by bonemineral density assessment.She retums 2 yearslater for another DXA scan. She
discontinuedestrogentherapy 2 yearsago. Her mother sustaineda hip fracture at age 75 years.
Shehasno personalhistory of bone fracturesand takes 1000mg of elementalcalcium and 400
IU of cholecalciferolin a multivitamin daily. Shehas never usedglucocorticoids.Sheis healthy
andexercises3 times a week.
Baseline Z-Year Follow-
R"gln .{aE EMC, EMD, T- 7- Regron Aftn EMC, BMD, T- F.

cml acoE ttoE tml d.*t tcotr ttoE
d.*t
11 . ? 0 0.929 -rl.8 -[.1 LI 1l.38 L64 0.84? -0.4
L1 1tt.86
-1.0 -0.0 L' 12.t5 1 1. 3 5 0.934 -rt.5

I_2 1 1. 9 6 12.16 l.011
-rt.4 t: t4.22 13.6J 0.960 -t.8

t3 14.10 14.46 1.026
L4 16.58 16,J4 0.991 -1.0 U l6.69 16 . 1 3 0.96? 1.3 1.0
5434 5402 0.994 -1.4 -{t.4 Total 5d44 50.?7 0.!33 -2.0 -{l.T
Totrl
tr{}ts**{""}#sT**rd$81
$:s&$3
Baseline
ngm irral Btilc, Etq T. L llrliqt irttr xMf, Dlq T. t

ml g !/mr r(G t(@ mr c g/m' tam r(&
$.* 49J 3.{2 0691 -18 -13 Nrr! 500 -lt
3.16 0633
tp(lr 902 J4J 060J -o8 I066
tD(h 6.14 OJlE IJ {t9
tts 16.7J 16.4' 0gil -o9 ltE 1625 lJ.{8 09.s -I.1 -{9
T{hl 30.11 tSgl 0trr -lt -o9 Tolif 3l 9t ?{n 017? -tf -ltl
Wud's r30 0t3 0Ja -le {J l rud'5 130 tE7 0J16 4b
On review of systems,her weight is stable and she has no gastrointestinalsymptoms.

On
physical examination, blood pressureis 120184mm Hg, and heart rate is 86
beats/min. She
weighs 150 poundsand is 64 inchestall (BMI :25.7 kg/mr). Shehasno signsof Cushing
syndrome. Social history is notable for smoking cigarettes.She drinks I glass of red wine
every
night.
You review her baseline and follow-up bone mineral density by DXA of the spine and
hip.
The 2 studiesare performed on the samemachine.
Wich one of thefollowing statementsindicates how you should counsel this patient?
A. She should begin therapy with an antiresorptiveagent (anticatabolic)
B Except for lifestyle modification, no additional therapy is needed
C. Therapy should be determinedon the basis of whethir a bone turnover marker is elevated
D. She should begin therapy with an anabolic agent
E. The DXA scanscannot be comparedand must be reanalyzed
112
Question
A 48-year-oldwomanis referredfor evaluationof obesityandhypertension. Shehasbeen
overweightfor mostof her adultlife, andher weighthasbeenstablefor theprevious3 years
at 211pounds.Shehastried multipledietsandbehavioralprogramswithouiany long-lasting
success. Shehasbeentreatedfor hypertensionfor thepast4 years,with increasingriedication
needsto maintainadequate control.Shepreviouslyhadmodesthyperhiglyceridemia, with
valuesrangingfrom 310 to 380 mg/dL,andLDl-cholesterollevelsrangingfrom 145to
160mg/dl. Repeatedmeasures of fastingglucosehaveshownnormalvalues.Currently,she
takeslisinopril,amlodipine,and athiazidediureticfor her bloodpressure;gemfibrozilfor
hyperlipidemia;andnonsteroidalanti-inflammatory medicationsior low backpain. Shedoesnot
smokecigarettes.Shehasa strongfamily historyof coronaryarterydisease.
BMI is 32kglm2,andbloodpressureis l48ll02 mm Hg. Shehascentralobesitywith a waist
circumference of 91 cm. Findingsfrom examinationof theheartis normal.peripheialpulsesare
normal, but there are bilateral carotid bruits. She has no stigmata of Cushing ,yndro1n.-.
82 ESAP2OfO-QUESTION$
Fasting glucose : 98 mgldl-
LDL cholesterol: 13l mg/dl
TSH: 1.1mIU/L
Sodium: l4l rnEilL
Potassium:4.1nlBq/L
Plasmaaldosterone: 12 ng dL
Plasmarenin activity : 1.2 nglmLlh
24-Hotx urine collection for catecholamines,metanephrines,and cortisol is normal. The patient's

primary care physician has encouragedher to lose weight and sent her to a dietitian. The patient
is frustratedthat she has not lost weight with diet and wonders if there are other approachesshe
coulduse.
Wich one of thefollowing strategies is the most appropriate approach to this patient's obesity?
A. Sibutramine
B. Orlistat
C. Fluoxetine
D. Referral for bariatric surgery
E. Sibutramineand orlistat
Question
113
You are askedto seea 62-year-old man with newly diagnosedtype 2 diabetesmellitus. His
conditionwas discoveredjust 2 weeks ago when he was admitted to the hospital for treatment
of a myocardial infarction without S?segment elevations. Atthattime, he was found to have
multivesselcoronary artery diseaseand underwent coronary arterybypasssurgery.
During the perioperativeperiod, his glucose levels were maintained in the referencerange
via intravenousinsulin infusion. While in the hospital, he had clinical evidenceof congestive
heartfailure with a left ventricular ejection fraction of 30%o;he did not have any arrhythmias.
His serumcreatinine concentrationwas 1.0 mgldL, and his hemoglobinA," level was 12.5%o.
He andhis wife met with a dietitian during the hospitalization,but becausehis wife has diabetes
mellitus,both already adheredto medical nutritional therapy.Before discharge,he was prescribed
glipizide,5mg twice daily.
His current medications include carvedilol, 12.5 mgtwice daily; pravastatin,20 mgdaily;
aspirin,325 mg daily; lisinopil,20 mg daily; isosorbidemononitrate, 30 mg daily; furobemide,
40 mg daily; and glipizide, 5 mg twice daily.
wich one of thefollowing is the best choicefor treating his diabetesnow?

A. Discontinuethe glipizide and prescribe metformin
B. Continuethe glipizide and prescribe athiazolidinedione
C. Continuethe glipizide and prescribe metformin
D. Continuethe glipizide and prescribe insulin
E. Discontinuethe glipizide and prescribe insulin
ESAP201O-QUESTIONS
83
Question114
A 40-year-old man seeksyour opinion regarding a recent history of erectile dysfunction.

His
erectile problems began approximately 2 years ago and have slowly, but steadily,
worsened.He
has occasionalmorning erections,but cannot maintain an erection through inteicourse.
This has
resulted in an increasingamount of tension between him and his wife.
He has a l9-yeat history of type 2 diabetesmellitus and was treatedwith multiple
oral agents
for approximately 16 years. His glycemic control remained poor during that time.
His therapy
was then changedto insulin and metformin, and although he has had better glycemic
control in
recent years, his hemoglobin A," level has been consistently in the 7%oto T.io6range.
He has a 3-
year history of hypertensiontreatedwith an ACE inhibitor; background retinopathy;
and stable,
mild nephropathy (urinary protein excretion, 175 mg/24 h; creatinine clearance,
Oi'mUmin1.
Medications include 70130insulin, 60 units subcutaneouslyeach morning and 30
units
subcutaneouslyeach evening; metformin, 1000 mg orally twice daily; lisinofril, 20
mgorally
each morning; aspirin, 80 mg orally each morning; and a multivitamin.
On review of systems,he has no cardiac symptoms. He does have mild numbness
and
tingling in both feet, which is worse in the evening hours. He has no postprandial
bloating, pain,
or postgustatorysweating.
Physicalexaminationrevealsan overweightman (BMI :28.2kglmr). Blood pressure
is 132180mm Hg. Funduscopic examination reveals scatteredmicroaneurysms
without
neovascularization.Findings from cardiac,pulmonary abdominal, and genitourinary
examinationsare nofinal. Neurologic examination shows a mild reduction in sensation
to light
touch in both feet.
Wich one of thefollowing treatmentdecisions would be most likely to help with the
erectile
dysfunction?
A. Initiate treatment with a phosphodiesteraseinhibitor
B. Discontinue metformin
C. Replace lisinopril with atenolol
D. Intensify the insulin regimen to basal/bolusregimen to reduce his hemoglobin
A," level to
less than 7oh
E. Add clopidogrel to low-dosage aspirin
Question115
A 40-year-old woman is referred to you for further evaluation of increasedlevels

of fractionated
catecholaminesand metanephrinesand abnormal abdominal CT findings in the setting
of new-
onsethypertension. She is currently treated with an angiotensinII receptor antagonisf
and
the hypertensionis suboptimally controlled. Her weight has been stable. She hai no'rigr6
o,
symptoms suggestiveof Cushing syndrome,pheochromocytoma,or hyperaldosteronism.
Her
only medication is losartan, 100 mg once daily.
on physical examination,BMI is 28.2kglmr,blood pressureis 130/90mm Hg, and
heart rate is 96 beats/min.The patient appearswell. Findings from abdominal anJlymph
node examinationsare normal. Findings from the remainder of the physical examination
are
unremarkable,including thyroid palpation.
To evaluatethe clinical importance of the CT findings, you order laboratory tests,
which
provide the following results:
Plasmaaldosterone:7 ngldL
Serumcortisol after 1-mg overnightdexamethasone suppression: 0.9 pg/dL
84 H$Ap?S1S*Q{",'C$flSru$
Plasmafractionatedmetanephrines:
Metanephrine : 0.4 nmol/L
Normetanephrine : 15.4nmol/L
Plasma reninactivity: I nglml-perh
Urinarycreatinine: ll23 mgl24h
Urinarydopamine :232 Vg2ah
Urinaryepinephrine : ll pgl24h
Urinarymetanephrine:132pgl24h
Urinarynorepinephrine : 919 pgl24h
Urinarynormetanephrine : a$a pgl24h
Urinevolume:2.1Ll24h
Axial CT imageof the abdomen.

Whichone of thefollowing disorders is most consistentwith the CT image and biochemical
profile?
A. Multiple endocrineneoplasiatype 2A
B. Cameytriad
C. Multiple endocrineneoplasia type ZB
D. Familial paraganglioma/pheochromocytomaassociatedwith an SDHC mutation
E. von Hippel-Lindau syndrome
Question
116
A 56-year-oldman presentedto the emergencydepartmentwith acutemidthoracic back pain
that
occurredwhen he lifted a box. X-ray revealeda compressionfracture of the Tl0 vertebraand
generalized
demineralization.The primary carephysician performed a DXA scan,and the findings
wereconsistent with osteoporosis(T scores:-2.5 atthe lumbar spineand 1.7 inthe hip). She
refenedthe patient to you.
His medical history is relevant for a midfemoral fracture at age7 yearswhen he fell off a
junglegym, a left radial fracture at age 8 yearswhile skiing, a right radius
fracture at age9 years
whileplayingbasketball,and a coccygealfractureat age30 yearswhen he slippedon ice. He
was
diagnosed with conductivehearinglossat age35 years.
He reportsthat his motheris 64 inchestall, and shehasseverekyphoscoliosisand a history of
frequentfracturesas a child. His fatheris 72 inchestall, and he hashypertension.The patient,s5-
year-oldsonhasexperienced8 fractures.
On physicalexamination,the patientis 66 inchestall. He hasslightly bluish sclerae,normal
dentition,
andnormal skin andjoints. An examinationof his spinerevealsmid-lower thoracicpain
atthemidline.Findingsfrom the remainderof the examinationare normal.
Whichone of thefollowing statementsis true?

A. He hasan X-linked syndromeof deafness,bowed legs,kidney stones,and short
stature
B' Fracturepreventionby increasingoral calciumand avoidingphysicalactivity
is indicated
c. Intramedullaryrodding of all limbs is necessaryto prevent fui1herfractures
D. Genetictestingof leukocyteDNA may be usefulto establisha diasnosis
E. Thehearinglossis due to pendredsyndrome
Question
117
A25-year-oldwoman is referredto her gynecologistbecauseof oligomenoruhea.
This problem
started
severalyearsago.At first, shebeganto skip occasionalperiods,but the intervaf
between
ilsAp **$**-*i"i#$"f$#&i# 85
menstrualperiods has increasedin length and shehas had only 2menstrual periods
over the last
year. Pelvic examinationfindings are normal, and she doesnot have acne
or hirsutism. Her serum
prolactin concentrationis 2 l0 ng/mL, and when serial dilutions are performed,
prolac tin is 202 ngl
mL' She doesnot report having galactorrhea,but on physical examination,her gynecologist
was
able to expresswhitish secretoryproducts from both nipples. The gynecologistreferred
the patient
for endocrineconsultation.
In taking a history you learn that the patient had to intemrpt ayear in college
becauseshe
developedschizophrenia.Initially, she was treated with olanzapine,but did not
want to continue
it becauseshe gained so much weight. After trying severalother antipsychotic
medications, she
was prescribedrisperidone, which has been helpful.
Wich one of thefollowing is the best next step?

A. Changeher antipsychotic medication
B. Test for macroprolactinemia
C' Order pituitary MRI
D. Add bromocriptine
E. MeasureIGF-I
118
Question
An S2-year-oldman with aggressivemetastaticcarcinoma of the prostate gland

has lost 10
pounds over 3 months. He is enrolled in a clinical trial of a high-dose
conjugatedestrogen
treatment of androgen-independentprostate cancer.The patient's urologist
finds a tremor on
physical examination-and,becauseof weight loss and tremulousness,
screensfor thyroid disease
by measuring serum-freeTo and Tr. The patient is referred to you when the
urologisi concludes
that the patienthas T, toxicosis.
The history you obtain from the patient establishesthat except for weight
loss, there are
no symptoms attributable to thyroid disease.The patient reveals he is taking
I I prescription
drugs, including digoxin, furosemide, a
B-adrenergicblocking agent,andan anti-parkinson
diseaseagent.You learn from the patient that his spousehas hypothyroidism
that is treatedwith
desiccatedthyroid tablets.
on physical examination, the patient is an elderly man who reports pelvic pain.
He has
a heart rate of 84 beats/min and a regular cardiac rhythm. The thyroid gLnd
cannot be felt,
but the patient is kyphotic and the anterior aspectof the neck is difficult
to examine. He has
frank gynecomastia.A rest tremor is noted and there is cogwheeling
of the wrists.'Deep tendon
reflexes are barely detectableat the biceps and ankle.

SerumTSH:0.6 mIU/L
Serumfree To : 1.2 ngldL
Serumtotal T, :220 ng dL
Ilhich one of thefollowing is the most likely conclusion?

A. The patient probably has endogenousT, toxicosis
B. The patient is euthyroid and the T" concentrationis erroneous
C' The patient is euthyroid and has an elevatedthyroxine-binding globulin
concentration
D. The patient has been taking his wife's desiccatedthyroid tablets
E' The elevatedserum_ T, concentrationprobably reflects mild resistanceto thyroid hormone
unrelated to the patient,s prostate carcinoma
86 ESAP
2010*8UE$Tt0r'I$
Question
119
You are askedby the transplant team at your hospital to seea 55-year-old man
with poorly
controlledtype 2 diabetesmellitus and hyperlipidemia.The patientunderwenta cadaveric
liver transplant3 yearsago for cirrhosissecondaryto nonalcoholicsteatorrheic
hepatitis.
He hashad diabetesfor 10 yearswith poor glycemic control while taking a combination
of oral hypoglycemic agents.However, with the developmentof both renal insufficiency
(serumcreatinine,2.0 mg dL) and elevatedliver enzymes,therapy with
metformin and a
thiazolidinedione was stopped,and he was recentlyprescribedinsulin. He has graduallytitrated
his insulindosageupward and is currently taking 100 units of insulin glargine
ut b"dti-" and 50
unitsof insulin lispro beforemeals.He statesthat his glucoselevels are never
below 250 mg/dL
andare frequently between 300 and 500 mg/dl. You confirm this by checking
the results on the
memoryof his home glucosemonitor.
His medicationsinclude insulin; warfarin, 2 mg every other day; propranolol,l0
mg twice
daily;enalapril,10 mg once daily; furosemide,g0 mg twice daily; cyclosporine,
150 mg once
daily;and clonidine patch,0.2mg appliedonce weekly.
On physicalexamination,you note a middle-agedman with a blood pressureof 160192
mm
Hg, hearlrate of 90 beats/min,and weight of 265 pounds(BMI of 32 ki^).His
waist to hip
ratiois 0'92' His skin is normal with no rash or xanthomas.Funduscopicexamination
reveals
mild backgroundretinopathywith scatteredmicroaneurysmsand hard exudates.
Auscultation
of his chestrevealsclear lung fields bilaterally.Distant but normal S, and S, heart
soundsare
audiblewithout other cardiacabnormalities.His liver is enlargedwhen percussed
and slightly
tenderto palpation.He has a palpablespleen.His feet show no areasof skin breakdown,
but his
pedalsensationis diminishedbilaterally.
You obtaina hemoglobinA," measurement,which is 6.2%o.
LVhichone of thefollowing additional testsshould you now order to help determine

the
discrepancybetweenhis home glucose monitoring results ond hishemigtobin A,"
level?
A. Continuous6- or 7-day glucosemonitoring
B. Reticulocytecount
C. White blood cell count
D. Serumhematocrit
E. Hemoglobinelectrophoresis
Question
120
1^47-year-old woman is evaluatedfor a 6-month history of oligomenorrhea.She is otherwise

wellandhasnot seena physician for 5 years.Shehas not beenhospitalizedsince
deliveringher
second child l5 yearsago. Shetakesno medications,doesnot smokecigarettes,and drinks
wine
with dinnerseveraltimes a week. Sheis sedentaryand follows no specificdietary
regimen.There
is no family history of early coronary artery disease.Both parentsare alive and in good
health.
On physicalexamination,blood pressureis 126178mm Hg. Sheweighs 180pounds
and
is 66 inchestall (BMI :29 kglm2).Waist circumferenceis 86 cm. The thyroid gland
is normal
onpalpation.There are no cutaneousor tendinous xanthomata.Findings from cardiac
and
abdominalexaminationsare unremarkable.
Totalcholesterol: 265 mg dL
Triglycerides: 80 mgldl,
tr$&p?*rs*ftilm$?$*rus87
HDL cholesterol: 70 ms.ldL
LDL cholesterol: iD};s/dL
Glucose:80 mgldl-
TSH : 1.0mIU/L
FSH: 27IU/L
In addition to referral to a dieticianfor

instruction in a diet reduced in cholesterol
and encouragementto begin ,"gLh, exercise, and saturated
fat what wourd you recommend?
A. No drug therapy
B. Rosuvastatin
C. Cholestyramine
D. Fluvastatin
E. Ezetimibe
Question
121
A 5l-year-old woman comesto your office

with a chief concernof hot flashesfor the last
months' She reports that she has had regular,menstruat 6
cycles fo, most of her life,2 termvaginal
deliveries, and normal.findings from gfrecologic
examinationsand papanicolaou smears.
Her last menstrualperiod was 10 -onitt,
ago. Hot flashesoccur severaltimes a day
associatedwith diaphoresisand moderate and are
discomfort. The hot flashesand associated
intemrptions are interfering with her ability sleep
to function and have left her feeling fatigued
less sharp mentally' She has tried increasing and
her dietary.of inot. and has had only minimal
relief from an over-the-counterphytoestrogen
- supplemlnt. she would like to speakwith you
about initiating hormone therapy.
Medical history is notable for borderline
hypertensionand impaired glucose tolerance,
she is not taking any medications. she has but
had no operationsuno r.port, having normal
from a screeningmammogram and a colonoscopy findings
6 months ago.A DXA scanperformed last
month demonstratedlow bone density (osteopenia).TIer
yo,rn!", brother was recently diagnosed
with colon cancer at age45 years. Her iattrer
aied of luni .unJ., at age67 years,andher
has osteoporosis.Sheis sexuallyactive. mother
she doesnot sm"oke
on physical examination,she is 65 inches "igur"tt.r.
tall and *"igtr.l?o pounds(BMI: 26.6kg/mr).
Blood pressureis 134185mm Hg. Findings
from the r",nuiio..of her physical examination
normal. are
wich one of the.following hormone therapy

regimens wourd be safest in this patient?
A. Combined oral contraceptive
B. Transdermalestradiol with orar micronized
progesteronefor 7 days each month
c' Transdermalestradiol with placement of
a levoiorgestrel inirauterine system
D. Continuous oral estradiol
E. Daily conjugatedequine estrogenswith
medroxyprogesterone
Question
122
A S2-year-oldman seeksevaluation of his

symptoms. He statesthat for the last 6 months,
has been feeling very tired and weak and he
has.been experiencing excruciating pain all
body' which initially startedin his legs. Medical over his
history is notaile for rib and pelvic fra*ures,
hypertension,and hyperlipidemia. M-edications
include atenolol.50 mg daily; atowastatin,20
mg daily; aspirin, 8l mg daily; and a multivitamin.
88 n$&p?str$*QUH$Tt$rus
On physical examination,hearirateis T6beatslmin and blood pressue is I47/87 mm Hg. He
appearsto be in pain. Oral mucosa is moist, heart soundsare regular with no murnurs, and lungs
areclear.There is tendernessto palpation over the chest wall and mild kyphosis. His abdomenis
soft with mild tendernessin right lower quadrant;no organomegalyis noted; and normal bowel
soundsare present.Findings from the remainder of the examination are unremarkable.
Serum:
Hemoglobin:9.9 gdL
1,25-DihydroxyvitaminD, : 5.0 pglml
IntactPTH :52pgmL
PTHrP : <2.0 pmoVl
Albumin:3.3 g/dL
Total calcium : 8.6 mg/dl
Creatinine: 1.0 mgldl-
Phosphorus: 1.8 mg/dl (2.9 mgldL 1 year ago)
Urine:
Volume: 1100mL24h
Creatinine: 2000 mgl24 h
Phosphorus:1600m!24h
Calcium:250 mgl24h
Whichone of thefollowing will most likely determine the causeof his hypophosphatemia?
A. Measuringurinary cross-linked Ntelopeptides of type I collagen
B. Performing serumprotein electrophoresis
C. Measuring 24-hour urinary cortisol
D. Measuringfibroblast growth factor 23
E. Performing CT or MRI
123
Question
{24-year-old woman is referred for advice regarding the managementof diabetesmellitus

duringher first pregnancy.She is in the 12th week of gestationand has been using an insulin
pumpfor 3 years. She has no known complications of diabetesand has continued to check her
bloodglucosefrequently during pregnancy.
Hemoglobin:9.8 gldL
MCV:75 pm3
Redblood cell distributionwidth : 18.5%(referencerange,lr9%-155%)
White blood cell count :5600/ytL
Plateletcount: 165 x l}3lpL
Alkaline phosphatase: 265 UIL
Alanine aminotransferase: 25 Ufi,
Fastingglucose= 72 mgldL
HemoglobinAr":5.2Yo
TSH: 2.4 nIUIL
E$Ap2018*QUE$T|O'{S 89
Tissue transglutaminaseantibodieswere detected,
and celiac diseasewas presumptively
diagnosed.Iron and multivitamin supplementation
was recommended.
Wich one of thefollowing would you do now?
A. Measurered blood cell folate concentration
Recommendthyroid hormone replacement
I
Suggestthat the patient focus on postprandial
I glucose control
D' Suggestthat the patient loosen grycemic
control to avoid hypoglycemia
E. Recommendcolonoscopy
Question
124
You are askedto evaluatea 6l-year-old woman
with severecoronary arterydiseasefor
secondaryprevention' She initially presented
with chestpain and an inferolateral myocardial
infarctionat age56yearsandhadastent_placedin theriiht ;;;;;;;;.
subsequent myocardial ffiffi
infarctionat age58.r9ar1,
rorro*iJ uv a 3-vessel " graft.
Shewasrecentlydischargedfrom the-hospiial coronary bypass
afterun of unstableangina.Findings
from coronaryangiographydemonstrated obstructiooof"pirode
1 of th" bypassgraftsanddiffi.rsedistal
arterialdisease.
she hasa family historyof prematurecoronary
diseasein her maternalrelatives.Shehas
neversmoked'hasnot beentreatedfor hypertension,
andhasalwayshadnormalplasmaglucose
levels'Normalresultsweredocumented from un o.ul gtu.or" iot"rancetest ayearago.
cholesterol,HDl-cholesterol,andhiglyceridelevels Her total
havebeenwithin thereferencJrange, and
her LDl-cholesterollevel hasbeenriaintained-_under
r00 mgfir with simvastatin,20mgdaily.
Shehasmild andstablechronicrenalinsufficiency
rrtouirr,to be dueto an adversedrug
reactionthat occurredmanyyearsago.There
is no hisiory oihepatic or gastrointestinal
disease.
simvastatin,
shetakeJong-acting
nitrates,
anACEinhibitoa
lHlt:?lJo aspirin,
anda B-
BMI is 26 kglm2,andbloodpressureis ll5./70
mmHg.on physicalexamination,her skin
is paleanddry' Thereareno cutaneous
or tendinousxantiomata.strehasan enlargedpoint
maximumimpulse,a soft systolicmurmur,a clear of
chestexamination,andno peripheraledema.
Findingsfrom her neurologicexaminationare
normal,andshehasdecreased peripheralpulses.
Totalcholesterol: 154mgldL
Triglycerides: 101 mg/dL
HDL cholesterol:47 mg/dL
LDL cholesterol: g2 ms/dL
TSH: 1.8mIU/L
Fastinghomocysteine:15.2pmoW
Serumureanitrogen: 42 mg/dL
C-reactiveprotein,high sensitivity: 5.0 mgll,
Lipoprotein(a): 17 mgldL
wich oneof thefoilowingwourdbe themostappropriate

interventionnow?
A. Gemfibrozil
B. Antioxidantvitamins
C. Fenofibrate
D. Cholestyramine
E. VitaminsBu,B,r, andfolate
90 ESAp2010*QUESTTONS
125
Question
A48-year-old woman who smokes2 packs of cigarettesper day has hyperthyroidism that
is well controlled by methimazole, 10 mg daily. She has no concernsother than worsening
discomfortin her eyes.Her eyes are always red and initated with excessivetearing; she has
occasionalepisodesof double vision when looking upward and to the right. She consultedher
ophthalmologistI month earlier and had normal visual acuity then. Proptosis was measuredat
25 mm bilaterally (Hertel exophthalmometer).She was prescribedprednisone,60 mg daily; that
dosagewas progressively decreasedover the last 3 weeks before her visit. During that time, she
wastreatedwith prednisone,and the rednessand discomfort in her eyes improved dramatically.
However,all symptoms returned after the prednisonewas discontinued I week ago.
On physical examination, she appearseuthyroid. Her thyroid gland is still enlarged.She
hassymmetric proptosis that measures25.5 mm bilaterally. The conjunctivae are injected and
edematous.The periorbital tissuesare also edematous.There is impairment of upper gaze and.I
episodeof diplopia on looking up and to the right. Visual acuity and color vision seemnormal.
llhich one of thefollowing managementstrategies should you recommendnow?

A. Stop cigarettesmoking and return in 6 weeks
B. Startprednisoneagain at an intentionally high dosage(eg, 100 mg daily) and taper the
dosageslowly over 6 months
C. Startprednisoneagain at the lowest dosagepossible to control inflammation and refer for
orbital radiation
D. Treatwith cyclosporine
E. Referfor orbital decompression
Question
126
A 65-year-o1d man is referred to you for evaluation and

treatmentof a recently discoveredadrenal mass.He had
beenexperiencingabdominal fullness, and his primary care
physicianobtainedan abdominal CT scan. Serial contiguous
axialimagesfrom CT of the abdomenare shown.
The report from the radiologist includes the following
comments: "...Huge mixed densitylesion (large arrow) in the
regionof the left adrenal gland consistentwith adrenal cortical
carcinoma.There appearsto be tumor thrombus (small arrow)
extendinginto the inferior vena cava."
He feelswell, his weight has been stable,and he has no
historyof hypertension.
On physical examination, blood pressurejs 126/82
mmHg. BMI is 34.8k9/m2,and his excessbody weight is
symmetricallydistributed. There is b palpable mass in the
left upperquadrantof the abdomen.The rest of the physical
examinationfindings are normal.
Sodium:143 mBqlL
Potassium :3.9 mEq/L
Serumcortisol (8 AM) : 12.6 pg dL
ESAP20,I{}-QI.JESTION$91
PlasmaACTH (8 AM) :22 pgtmL
Urinary free cortisol :32 pg/Z4h
Plasmaaldosterone:36 ng/dL
DHEA-S :930 pgldL
Plasma fractionated metanephrines
Metanephrine : 0.2 nmoVl
Normetanephrine: 0.98 nmol/L
once he has recoveredfrom surgery, you should advise additional

treatment with which one of
thefollowing?
A. u-Methylparatyrosine (metyrosine)
B' Combination chemotherapywith cyclophosphamide,vincristine,
and dacarbazine
C. Radiation therapy
D. Spironolactone
E. Mitotane (o,p'-DDD)
Question
127
You are consultedby the cardiothoracic surgery service for the perioperative
managementof
glucose control in a 57-year-oldman who was diagnosed
with an acute myocardial infarction 12
hours ago' He has no history of coronary heart disease.He is
about to undergo coronary artery-
bypassgrafting.
In addition to stable hyperlipidemia and hypertension,well
controlled with a statin and a
calcium channel blocker, respectively,the patient has had type
2 diabetesmellitus for 5 years.
His diabeteshas been well controlled by twice daily sulfonylurea
therapy for the past 3 years
(hemoglobinA," level maintained at approximateli 7%).He
trasno known retinopathy, but does
have persistentmicroalbuminuria.
Wich one of thefollowing steps is the most reasonable to toke

during the perioperative period?
A' Avoid B-adrenergicblockers becauseof their tendency to
mask hypoglycemia
B. Initiate metformin therapy to improve his glycemic control
and lipidliofile
c. Initiate thiazolidinedione therapy to improve insulin sensitivity
D' Administer intravenousregular insulin and dextroseto
maintain his serum glucose values
between100 and 150 mg/dl
E' Provide no additional antiglycemic therapy until he is reassessed
as an outpatient 2 weeks
later
Question
128
{20-yeat-old woman comes to your office with the chief concern

of menstrual irregularity. Her
last menseswas 6 months ago. She reports the onset of menarche
at age14 years, and menses
becameregular at age 16 years. Thelarche occurred at agel1 years.
Her menseshave been
irregular for the last 2 years, and she reports that they * .orl
regular during the summer.
Medical history is unremarkable.She is a third-year college undergraduate,
and during the
schoolyear,shelivesinanapartmentwith2otherwomen.Shereportsaweight
gainof2pounds
over the last year, irregular eating habits, and consumption of
alcoholic beverlgef on weekends.
She statesthat she does not use other drugs. She has intermittent
headachesthat seemto be
related to staying up late at night before exams. She has a boyfriend
and is sexually active; she
statesthat he usually usesa condom. Her grade point averag i"
3.l,and she has loftv career
"
92 rsApps1{}*&t.Jffisx*rus
aspirationsthat include attending law school. She is aiming for a 4.0 grade point
averagethis
semesterto be eligible for summa cum laude. She exercisesregularly once weekly
by swimming
lapsand walks to and from school as often as possible to maintain fitness. She has
an intacr sense
of smell and reports no bingeing, purging, or laxative use. She thinks her weight
is appropriate;
sheeatswhen she remembersor when there is a social occasion. She likes school
and recognizes
thatit is a financial burden to her parents,whom she describesas supportive.
She has younger
siblings,all of whom are in good health. She reports no unusual stressors.She is
surpiised that
hermenseshave become more irregular and worries about future fertility.
On physicalexamination,she is 66 inchestall and weighs 130 pounds(BlfJ: 2I kgl
m'z)'Findings from her examination are otherwise unremarkable.Escutcheonand
breastsare
Tannerstage5, habitus is gynecoid, and there are no striae or areasof hyperpigmentation
or
hypopigmentation.Hair distribution is normal with a few periareolar hairs and
vellus sideburns.
MRI of the head is normal.
TSH: 1.0mIU/L
FreeTo: 0.5 ngldl,
Estradiol:45 pglmL
FSH: 5.61U/L
LH:4.O IU/L
Progesterone: 0.5 ng/mL
Prolactin:7.8 nglmL
Urinary pregnancy test, negative
Wich one of thefollowing treatmentswould best restore ovulatory cycles and preserveJbrtitity?
A. Oral contraceptives
B. Stressmanagementtechniques
C. Metformin
D. Psychiatricreferral
E. Bisphosphonate use
Question
129
A4l-year-oldAfricanAmerican woman is referred to you by her primary

care physician who
is uncertainof her metabolic diagnosis. She has a very strong a-ify hisiory
of typ" 2 diabetes
mellitus,and her mother, maternal grandmother,and older biother are affected.
ihe patient was
very concernedthat she might also develop diabetesand askedher primary
care physician to do
anoral glucosetolerancetest. However, the primary care physician was confused
by the results.
Thepatientis obese(BMI : 32kdnf), Blood p."s*" is 142/86mm Hg.
Shehad l'baby
weighing9 pounds, 6 ounces,but the patient was not diagnosedwith gestational
diabetes.
LDL cholesterol: 118mg/dl
Electrolytes,normal
An oral glucosetolerancetest done with a 75-g glucose load reveals the following
values:
baseline,109 mgldL;60 minutes, 267 mg/dL; and,120minutes. 133 ms/dL.
ffi$Ap,$10*9Lt E$Tr0h,$ 93
Wich one of thefollowing can you tell thepatient about the importance of these testresults?
A. The patient has isolated impaired fasting glucose-prediabetes-and should institute
appropriatelifestyle changes
B. She has nothing to worry about for now becauseher 2-hour glucose value is less than 140
mg/dL; she should be retestedin I year
C. She has diabetesbecauseI of the postchallengeglucose levels is greater than 200 mgldL;
she should therefore start metformin
D. She has combined impaired fasting glucose and impaired glucose tolerance; she has a high
risk of diabetesand should start metformin now
E. Measuring hemoglobin A," is the only appropriatemethod to diagnoseprediabetesin this
case
130
Question
The cancer center refers a 53-year-old man with locally metastaticrenal cell carcinoma and
abnormal serum thyroid function test results. The patient was treatedwith radical nephrectomy
when he was initially diagnosed2 yearsearlier. Three months ago, routine follow-up chest
x-ray revealedprobable lung metastases,and findings from a radiologically guided biopsy of
a peripheral lung lesion confirmed renal cell carcinoma.The patient has been recently treated
with bevacintmab (Avastin), a monoclonal antibody to vascular endothelial growth iactor, and
sunitinib (Sutent), an oral tyrosine kinase inhibitor shown to be efficacious againstmetastatic
renal cell carcinoma.
The patient reported constipation, and a serum TSH concentrationwas found to be elevated.
one year earlier, serum thyroid function test results were normal.
Your physical examination reveals a healthy appearing,thin, middle-aged man with normal
vital signs. The only notable findings are a well-healed left flank surgical scar and frankly
delayedrelaxation phase on ankle deep tendon reflex testing.

SerumTSH: 29 nIIJIL
Serum free To = 0.48 ngldL
Serumtotal T, :70 ngldL
Wich one of thefollowing best describesyour impressionof thepatientb condition?

A. The patient has biochemical and early clinical hypothyroidism, probably due to sunitinib
treatment
B. The patient has biochemical and early clinical hypothyroidism, probably due to Hashimoto
thyroiditis, and thyroperoxidaseantibody titer measurementis needed
C. The patient has biochemical and early clinical hypothyroidism, probably due to bevacizumab
treatment
D. The patient has nonthyroidal illness syndrome due to renal cell carcinoma
E. Thyroid dysfunction in this patient reflects metastasesof renal cell carcinoma to the thwoid
gland
131
Question
A 3S-year-oldJapaneseman comes to you becausehe is concernedabout hypoglycemia. He

statesthat 3 to 4 years ago he began to experiencesymptoms of generalizedweaknessand
diaphoresis.These symptoms usually occur severalhours after eating a meal. The main item
94 ESAP201S_QI.JESTIONS
in his diet is steamedrice. On one occasion,he checkedhis blood glucose concentrationon a
capillaryglucose monitor and found it to be 25 mgldL. He had a random serum glucose level of
45 mgldL measuredseveralweeks ago in the emergencydepartment.He statesthat his symptoms
usuallyresolve within 30 minutes of eating or drinking concentratedcarbohydrates.He has never
experiencedloss of consciousnessor seizures,but notes that his symptoms are occurring with
increasingfrequency and severity. He gives a history of borderline hypertension,but is currently
taking no medications.He notes that he had a severecaseof contact dermatitis last year which
wastreatedwith glucocorticoids; during that time, he thought his symptoms, which he attributes
to hypoglycemia, abated.He has no family history of diabetesor neuroendocrinetumors.
Physical examination reveals a healthy appearingman. Blood pressureis 140/95 mm Hg,
heartrate is 90 beats/min, and his BMI is 24 kglrfi . Results from a urine sulfonylurea screen,
which had been performed during an earlier visit to the emergencydepartment,were negative.
Wich one of thefollowing is the most appropriate next test?

A. 72-hour fast
B. MeasureC-peptide level
C. Measureinsulin antibody titer
D. Perform CT with fine cuts through the pancreas
E. Measureproinsulin level
132
Question
A 40-year-oldwoman is concernedabout fatigue, obesity with inability to lose weight, and poor
muscleshength. She was always short and did not grow after age 1l yearc. She had primary
amenorrhea,but breast developmentwas normal. She was found to have a sellar mass at age
23 years.At surgery a Rathke cleft cyst was removed. Postoperatively,she developeddiabetes
insipidusrequiring tiny dosesof desmopressin.She had panhypopituitarism and required
hydrocortisone,15 mg daily, and levothyroxine, 100 mcg daily. Oral contraceptiveswere also
prescribed.Later, to achievepregnancy,she required gonadotropin therapy.
On physical examination, she is 59 inches tall and weighs 157 pounds (BMI : 31.7 kglmz).
Sheappearsvery young, but has some fine facial wrinkling. Her visual fields are intact. Findings
from the rest of her physical examination are unremarkable.
Whichone of thefollowing options is the best next step?

A. Measuresenrm cortisol
B. Perform MRI of the pituitary
C. MeasureserumIGF-I
D. Perform levodopa stimulation of growth hormone
E. Perform arginine stimulation of growth hormone
133
Question
You are askedto seea 5l-year-old woman with a history of prematuremenopause,which

occurredat age38 years, and recent diagnosisof osteoporosisby bone mineral density testing
determinedby DXA. She took estrogenand progesteronein the past, but stopped5 years ago
becauseof the controversiesregarding hormone replacementtherapy. She also has a history
of type I diabetesmellitus, iron deficiency anemia,and primary hypothyroidism. Medications
includelong-acting insulin once daily, short-acting insulin with meals, ferrous gluconate,
levothyroxine sodium, and an ACE inhibitor. She recently began taking a calcium supplement
anda multivitamin. She statesthat she does not take glucocorticoids.
ESAP2010-QUE$T|ONS95
Socialhistoryis notablefor nonsmokingstatusandno remarkablealcoholintake.On
physicalexamination,bloodpressureis Il8l74 mm Hg, andheartrateis 78 beats/min.She
weighs131pounds(BMI : 2l kglm'z).No signsof cushingsyndromearenoted.
DXA bonemineraldensitymeasurements:
Lumbarspine(L1-L4):T score: -5.0: Z scorc:4.2
Totalhip: T score: -2.9; Z-score: -2.2
Hemoglobin:I0 gldL
TSH:0.98 mIU/L
Alkaline phosphatase: 85 U/L
1,25-Dihydroxyvitamin D, : 96 pglmL
25-HydroxyvitaminD : 20 nglmL
IntactPTH :127 pglml-
Alanineaminotransferase: 15U/L
Albumin :4.0 gldL
Aspartateaminotransferase: l0 UlL
Calcium: 8.8mg/dl
Creatinine: l.2mgldL
Serumureanitrogen: l7 mg dL
Serumandurineproteinelectrophoresis, normal
Urinary calcium: 6 mgl24h
Urinary creatinine:950 mgl24h (referencerangebasedon bodyweight,
891to 1485mgt24h)
cross-linkedN-telopeptideof type l coilagen:22 nmollmmolcreatinine
wich oneof thefollowing is mostlikely toprovidediagnosticinformation?

A. MeasuringserumFSH
B. Assessingfor serumtissuetransglutaminase antibodies
C. Performinga sestamibiparathyroidscan
D. Measuringbone-specific alkalinephosphatase
E. Performinga bonebiopsy
Question
134
A 41-year-old woman with diabetesis referred becauseof numbnessand paresthesiasin her

feet and ankles. She has been treated for diabetesfor 9 years; the last 4 years, she has used
multiple daily insulin injections. She also has a history of obesity since childhood for which
she underwent a gastric bypassprocedure 5 months ago. After the operation, she had some
improvement in her blood glucose control, but has continued to require modest dosages
of
insulin (84 units daily comparedwith 235 units before surgery). She has lost22porriO, (346
to
324 pounds) in a postoperativecoursethat has been relatively uneventful excepffor intermittent
nauseaand vomiting.
Over the past 3 weeks she has developeddecreasedsensationin her feet that she reports has
led to clumsinessand occasionalstumbling. She has associatedmild paresthesias,but
does not
otherwise report abnormal sensationor pain. She has no weaknessor symptoms in her upper
extremities.
Blood pressureis ll3l79 mm Hg, and other vital signsare normal. BMI is 4l kglmz.
Findings from examinationsof the heacl,neck, chest,and abdomenare uffemarkable
except for
96 ESAP
201o*gur$TtoN$
obesity'Testing of the cranial nerves is normal. Her feet
are wafin without ulceration, erythema,
or sitesof increasedcallous. She has absentsensationto
monofilament testing to the level just
abovethe ankles and diminished vibratory sensein both great
toes.Achilles and patellar reflexes
aredecreased.Romberg and Babinski signs are present.
wich one of thefottowing is the most appropriate diagnostic

study?
A. Perform nerve conduction studiesand electromyography
B. Measureplasma 25-hydroxyvitamin D concentration
C. Perform upper gastrointestinalseries
D. Perform CT of the spine
E. MeasureplasmaB, and 8,, concentrations
Question135
A 60-year-oldwoman with a l5-year history of type 2

diabetesmellitus presentswith a
neuropathicfoot ulcer, which she was surprisedto discover
when she noied serosanguineous
fluid on her sock. This is her first foot ulcer. She reports
no fevers, chills, sweats,or pain. She
alsohashypertensionand dyslipidemia. She has a +s-packper
year history of cigarette smoking,
butquit l8 months ago.
Her medicationsinclude metformin, 1 g twice daily; glyburide,
5 mg twice daily; ramipril, l0
mg daily; aspirin, 8l mg daily; and fenofibrate, 200 mg
daiiy.
on physicalexamination,blood pressureis 130/90-mm
Hg ano pulse rate is gg beats/min.
Thereis arteriolar narrowing and occasionalmicroaneurysms
in the optic fundi. There is a right
carotidbruit and a left femoral bruit. The pulses in her
ankles and feei are weak but palpable.
Anklejerks are absent,and she can neithei appreciate
vibration in her great toes nor the l0-g
monofilamenton her plantar surfaces.There is no edema.you
observea 2-mm deep,2 x 4-cm
ulceron the secondmetatarsalhead of the right foot. It
clearly penetratesto the muscle, but no
bonecanbe identified. There is slight erythema around
the edgesof the ulcer, and it is draining
purulentfluid. The area surrounding the ulcer is
wann.
Erythrocytesedimentationrate: 25 mmlh
White blood cell count: 9000/pL
Randomserumglucose:240 mgldL
Ankle to arm index: right, 0.95; left, 0.65
Right foot x-ray: no evidenceof osteomyelitis
Whichone of thefollowing is the best next step in management?

A. Performa vascular bypassgraft to heal the ulcer
B' Immediatelyhospitalize thepatient for complete
bedrest,aggressivedebridement,and
intravenousampicillin/clavulanic acid
c' Performindium-labeled leukocyte imaging to rule
out osteomyelitis
D' Apply recombinanthuman platelet-derived growth
factor B in addition to performing local
debridement
E' Prescribeoral clindamycin, perform local debridement,
and instruct the patient to avoid
unnecessary ambulation
H$Ap20r0-guE$TroN$ 97
Question
136
Two years ago,a S7-year-oldwomanunderwent

total thyroidectomy to treat papillary thyroid
cancer'The pathology report noted a typical papillary
carcinoma ofthe thyroio, g.q in
diameter,adjacentto and_invading the thyroid "-
one of 6 local lymph nodes that were
"up.ui..
removed containedpapillary carcinoma.No evidence
was found of vascular invasion or invasion
of the surroundingtissues.
one month after surgery when she was not taking thyroid
hormones,her serum TsH
concentrationwas 41 mrlJ/L, and her serum thyroglobulin
concentrationwas 26 nglmL.
Thyroglobulin antibodieswere not detected.naaioioaioe
uptake in the neck was |.7%oat 24
hours, and the scan showed that the radioiodide
was localizld to the thyroid bed. She was treated
with 30 mci of r31I-A total body scan 7 days after treatment
showed radioactivity in only the
thyroid bed' She was then treated with levothyroxine,
125 mcg daily. During several subsequent
evaluations,neck examination findings were unremarkable
except for the healed scar.with this
levothyroxinedosage,the serumTSH concentration
remainedbetween0.0g and 0.23 mrrJ/L,the
serum thyroglobulin was less than 1.0 nglmL,and no
thyroglobulin antibodieswere detectedin
her serum.
Two years after thyroidectomy and radioactive iodide
treatment, she now comes to you for
further advice' she has had no interval concerns.Your
examination findings suggestthat she
is clinically euthyroid, and there are no palpable
abnormalities in her neck. The serum TSH
concentrationis 0'18 mrrJ/L, and the serum thyroglobulin
concentrationis less than 1.0 ng/mL.
Thyroglobulin antibodiesremain undetectable
1.i ruZ_I, ).
Wich one of thefollowing is the most reasonableapproach
now?
A' Stop levothyroxine treatment for I month and
then perform a total body radioiodine scan
with measurementof serum thyroglobulin, providei
that the serum TSH concentrationis
greaterthan 30 mlUlL
B. Increasethe levothyroxine dosageuntil serum
TSH is less than 0.01 'IU/L
C Perform high-resolution ultrasonographyof the
neck
D. Measure serum thyroglobulin aftei 2injections
of recombinant human TSH
E' Measure circulating thyroglobulin mRNA
by quantitative polymerase chain reaction
Question
137
4S2-yeat-old man is referred for evaluation of dyslipidemia

and new-onsetdiabetes.He has
long-standingHIV infection and has been receiving
iriglrty active antiretroviral therapy for
the past 5 years' He has not had HlV-related inrectioniand
his circulating markers of the
virus are undetectableon his current therapeuticregimen.
His antiviral regimen was changed
approximately 1 year agowith the addition of the piotease
inhibitoq ritonavir (Norvir). Since
that time, he has gained 16 pounds and developedlypertension,
diabetes,and hyperlipidemia.
other medical conditions include degenerativedisk
diseasefor which he receives steroid
injections every 4 to 6 months and chronic sinusitis
for which he usesan inhaled steroid/B-
adrenergicagonist preparation.He has been taking
metformin, hydrochloro thiazide, and
lisinopril the past 3 months.
Besidesthe weight gain, the patient reports new
symptoms of insomnia and fatigue. Despite
feeling poorly, his appetite has increased.
He weighs 177poundsand is 67 inchestall (BMI =
27.7 kg/m2).Bloodpressureis l2g/g2
mm Hg' on physical examination, the patient is generally
sligli, but has a protuberant abdomen.
He has facial fullness, but a paucity of subcutaneous
fat ou", hi. limbs. He has a small dorsal fat
98 E$AF2O1O*QUE$TIONS
pad and a waist circumference of 100 cm. There is
no plethora or bruising of the skin, but he has
violaceous striae apparentover the abdomen.proximal muscle
strength is 4+ in the shouldersand
reducedin the quadriceps.There are no cutaneousor tendinous
xanthoma.
Laboratory test results from analysis of blood drawn after
an overnight fast:
HDL cholesterol: 35 mg/dL
Hemoglobin Ar":6.90/o
TSH: l.2mlIJlL
Testosterone(total) :279 nglmL
CDocell count: 578/pL
Serum fasting glucose : l2g mg/dL
Wich one of thefollowing is the most appropriate diagnostic

study?
A. Direct measurementof LDl-cholesterol
B. Apolipoprotein E
C. Measurementof 8 AM cortisol andACTH
D. Oral glucose tolerancetest
E' Determinationsof plasma lipoprotein and hepatic
trigryceride lipase activity
Question
138
A 48-year-old man is referred to you for further evaluation
of recurrent catecholamine-secreting
paraganglioma'He underwent successfulremoval
of a mediastinal paraganglioma3 years ago.
Two months after surgery he completed a 100-mile bike
ride around the Grand Canyon, and 3
monthsago he climbed to the top of Mount Kilimanjaro
without difficulty. However, for the past
2 months,his symptoms of catecholamineexcesshave
refurned and include episodic palpitation,
diaphoresis,headache,anxiety, and pallor. Between episodes
he has marked anxiety and nausea,
he is koubled by a general senseof unease.He has increased
1d generalbody aches,and he has
lost l0 pounds. Recurrent hypertensionhas been diagnosed.
His medications include labetalol, 200 mgtwice daily; amitriptyline,
50 mg daily; diltiazem,
240 mgdaily; phenoxybenzamine,10 mg twice daily;
and-prochlorperazine,l0 mg as neededfor
nausea.
on physical examination, BMI is 29.1 kg/m2,blood pressure
is I 17149mmHg, and heart rate
is 97 beats/min.The patient appearsunwell-he seems
anxious and .orewed up.,, Findings from
the abdominal and lymph node examinationsare normal.
Findings from the remainder of the
physicalexamination, including thyroid palpation,
are unremarklble.
Plasmafractionated metanephrines:
Metanephrine : 0.29 nmbVl
Normetanephrine: l5.l nmol/L
Urinary creatinine:1443 mgl24h
Urinary dopamine : 5 150 pglZa h
Urinary epinephrine:2.6 pgl24h
Urinary metanephrine : 286 Vg/24 h
Urinary norepinephrine: 1736 pgl24 h
Urinary normetanephrine: 10,563 pg/2ah
Urinevolume:2.4L/24h
E$APEO,'O-QUESTIONS
99
CT of the chest,abdomen,and pelvis shows innumerable lytic lesions throughout the visualized
skeleton-the largest of theseare destructive lesions in the left sacral ala and the right iliac
bone, which measurejust larger than 4 cm. Multiple hypervascularlesions are seenin the liver,
and mild mesentericedemaand mild prominence of mediastinal,retroperitoneal,and peritoneal
nodes are indeterminate,but may also representmetastases.
To confirm that the metastaticdiseaseis indeed malignant paragangliomaand to help
determine treatment options for this patient, you order a r23l-metaiodobenzylguanidine (MIBG)
scan.
Which one of his medications may be continued during the MIBG scan?
A. Labetalol
B. Amitriptyline
C. Diltiazem
D. Phenoxybenzamine
E. Prochlorperazine
139
Question
A23-year-old man visits your office for the appearanceof a left testicular mass,fi.rstnoticed
approximately 2 months ago. It was nontender and found by the patient on self-examination
during a shower.He saw his primary care physician, and upon further questioning, mentioned a
4- to 6-month history of fatigue and erectile dysfunction, which prompted measurementof total
testosterone.This was low at 225 ngldL, and he was thus referred to you for further evaluation.
His medical history is remarkable for having salt-wasting congenital adrenalhyperplasiadue
to 2l-hydroxylase deficiency.He is treated with hydrocortisone, 10 mg each morning and 5 mg
each evening. He statesthat higher dosagesof hydrocortisone in the past resulted in substantial
weight gain and bruising. Otherwise, he takes no medications.He and his wife are not interested
in having children now.
Physical examination reveals blood pressureof 108/68 mm Hg with resting pulse rate of
88 beats/min.He weighs 127 poundsand is 66 inchestall (BMI :20.5kg1m2). Findings from
examination of the head, eyes, ears,nose, and throat are normal. Pulmonary cardiac, and
abdominal examination findings are normal. He has hyperpigmentationof the palmar creases
bilaterally. Genitourinary examination reveals a normal phallus and pubic hair. Both testesare
normal size. You find a nodule on the left testis, but no apparentmass on the right testis.
You order testicular ultrasonography,which documentsa2.2 x 2.1 x 2.6-cm mass on the left
testis.as well as a 0.8 x 1.0 x 0.7-cm masson the rieht testis.

Total testosterone: 198 ngldl-
DHEA-S:940 ytgldL
FSH:0.5ru/L
LH: <0.5ru/L
analysis
Semen showsuroo.o.rrniu.
Wich one of thefollowing is the best next step?

A. Increasehydrocortisone dosage
B. Perform a biopsy of both testicular masses
C. Initiate testosteronereplacement
D. Perform bilateral orchidectomy
E. Order MRI of the pituitary gland
100 rsApzs{s*Ql"fE$fisNs
140
Question
You are called to examine a 48-year-old man with end-stagemuscular dystrophy and.type2
diabetesmellitus. The patient has a history of severekyphoscoliosis and restrictive lung disease
leadingto recurrent pneumonia. He was admitted to the hospital 2 weeks ago with pneumonia
andrespiratoryfailure and has gradually improved with broad-spectrumantibiotic therapy.One
weekbefore consultation, total parenteralnutrition was started,consisting of dextrose, 185 g;
aminoacids,75 g; lipids, 10 g; and regular insulin, 20rJlL, administered at70 cc4r.Before the
initiation of total parenteralnutrition, his blood glucose concentrationranged between 150 to
200 mgldL. Since starting total parenteralnutrition, glucose concentrationshave been above 300
mg/dl. To treat his hyperglycemia, additional intravenousinsulin was startedand quickly titrated
upwardwith no improvement in his glycemic control. After consulting with you, his primary care
teamfirst askedthe pharmacist to check and reformulate his insulin preparation.However, his
bloodglucoselevels have remained above 300 mgldl-, and his intravenousinsulin infusion has
beenincreasedto its current rate of 8l ulh (approximately lg44ul24h\.
The patient has had hyperglycemia during past hospital admissionswhen he was treated
with glucocorticoids;however, he has received none during this hospital admission.His only
medicationsnow include antibiotics, terbinafine, and opioid narcotics for pain.
Findings from his physical examination are notable for a cachectic adult man with severe
musclewasting. He is afebrile and his vital signs are stable.His is receiving mechanical
ventilatoryassistancethrough a permanenttracheostomy,and a central line is in place with no
evidenceof inflammation, infiltration, or infection. There is no acanthosisnigricans.
Whichone of thefollowing will best determine the cause of his severeinsulin resistqnce?
A. Measureserum insulin antibodies
B. Stoptotal parenteralnutrition and intravenous insulin
C. Administer pharmacologic dose of hydrocortisone
D. Measurefree fatty acid concentration
E. Measureinsulin receptor antibodies
Question
141
A 7O-year-oldwoman presentsto the emergencydepartmentwith acutepain in her legs after

tripping on a rug and falling. She has a fracture of the proximal femur and is taken to the
operatingroom for an open-reductioninternal fixation of herhip. You seeher 3 months later for
managementof osteoporosis.She had a total hysterectomyat age50 years and is currently taking
conjugatedestrogen,625 mcgdaily, and calcium carbonate, 1250 mgdaily. She is also taking
omeprazoleand furosemide. She does not take glucocorticoids. Medical history includes peptic
ulcerdiseaseand lactoseintolerance.A gastrectomywas performed25 years ago.
Socialhistory is notable for nonsmoking statusand no remarkable alcohol intake. She states
thatshedoesnot have a family history of osteoporosis.
On physical examination, blood pressureis t l0/84 mm Hg, and heart rate is g2beatslmin.
Sheweighs 150poundsand is 64 inchestall (BMI :25.7 kg/m2),whichreflectsa loss of 3
inches.Shehasno signsof Cushingsyndrome.
DXA bone mineral density measurements:

L-Spine(Ll through L4): T score: 2.1; Z score: -1.5
Totalhip: T score:2.9; Z score: -2.2
H$AprsrCI*Q1"jm$Tt0eJ$
101
Hemoglobin:13.0g/dl.
TSH:2.1mIUIL
Alkalinephosphatase :345 UIL
l,25-DihydroxyvitaminD, : 15 pglmL
25-HydroxyvitaminD : 7 nglmL
IntactPTH :262 pglmL
Alanineaminotransferase : 15U/L
Albumin:2.9 gldL
Aspartateaminotransferase : 20 UlL
Calcium :7.1 mfldL
Serumureanitrogen: l7 mgldL
Serumandurineproteinelectrophoresis, normal
Urinarycalcium: 16mg24h
Urinary creatinine:900 mgl24h (referencerangeon the basisof body weight, 1022to 1703
mg/24h)
Wich oneof thefollowingis theoptimalinitial stepin treatingthispatient with osteoporosis?

A. Prescribeteriparatide
B. Prescribevitamin D supplementation
C. Prescribea bisphosphonate
D. Discontinueestrogentherapy
E. Continuecurrentcalciumdosase
142
Question
452'year-old man pqesentswith a chief concern of inability to lose weight. He reports steady
weight gain through young adulthood to a maximum of 266 pounds at age35 yeais. He was
diagnosedwith diabetesmellitus at that time, and his treatmentwas advancedfrom oral agentsto
insulin over the ensuing 17 years. He has tried multiple diets and sibutramine without successful
weight loss. Eighteen months ago, he had the laparoscopicplacement of an adjustablegastric
band with a follow-up band adjustment6 weeks later.After some initial weight loss, to a nadir
of248 pounds, he has regained weight and reports an increasedappetite over the past several
months. Based on values from home glucose monitoring, his blood glucose control has gotten
worse.
Blood pressureis 124176mm Hg, and BMI is 36 kg/m2.There is no glossitisor cheilosis.
Muscle bulk and strength are normal. His abdomen is obese,with active bowel soundsand no
tendernessor masses.Findings from neurologic examination are unremarkable.
Laboratory values at the time of evaluation:

HemoglobinAr":8.3Yo
Glucose : 193 mg dL
Hemoglobin:14.2 gldL
Hematocrit:43%
25-Hydroxyvitamin D : 60 nglml-
102 ESAP201g-QUESTTONS
-
whichone of thefollowing is the best next step in this patient's

care?
A. Upperendoscopy
B. Laparoscopy
C. Band readjustment
D. Low-residuediet
E. Nuclear gastric emptying study
Question
143
A 60-year-oldwomanwasin an automobile collision.
Findingsfrom CT performedin the emergency
department suggestthepossibilityof a pitoitu.y
mass.Thepatientunderwentmenopause at age42
years.
Shereportsno headaches, visualproblems,
galactorrhea,
or symptomsof acromeguiyo, Cushing
disease.
Laboratory
testresults:
TSH: 2,5mIUtL
FreeTo:1.3 ng/dL
8 AM corrisol: lg.2 pg/dL
Estradiol: <32pe mL
FSH:3.OIUIL
IGF-I = 150ng/mL
LH: 2.OIU/L
Prolactin:30nglml-
Coronalsectionof follow-up MRI.
wich oneof thefotlowingmanagement strategieswourdbe the bestnextstep?

A. Performa GnRH stimulationtest
B. Remeasure prolactinusingserialdilutions
C. Performtranssphenoidal surgery
D. Treatwith bromocriptine
E. Performconformalradiationtherapy
Question
144
Youareaskedto seea 44-year-oldwoman who has papillary
thyroid cancer.Her diseasewas first
diagnosedat age23 years. She had.a 2-stage(completion)
thyroidectomy, which revealeda 3-cm
encapsulatedpapillary cancer in the right lobe. The left lobe showeo
only chronic thyroiditis. She
wasthentreatedwith levothyroxine, 100 mcg daily.
About 5 years ago, she came under the care of an endocrinologist.
. - He performed a total
bodyradioactiveiodine scanthat showed uptake in the
right neck. The serum thyroglobulin
concentration was 35 nglmL. Shewas treatedwith 100 -gi r:r1.Another
scan,performed6 days
later,showedlocalization of radioiodine in 3 foci in
the right neck.
one year ago, becausethe serum thyroglobulin conceitration
remained between 5 and 15
nglmLwhile the serum TSH concentrationwas less
I than 0.4 mIIJ/L,she was given a second
I doseof radioactive iodine after 4ppropriatepreparation.The posttherapyscan
I -(13rI)
localizationof the radioiodine.
showed no
E$Apr010*Qiln$Tt0Ns
103
At a recent visit, the serum TSH concentration was 0.22 mIU/L and the serum thyroglobulin
concentrationwas 4 nglmL. Findings from a CT scan of her chest were normal 1 month ago.
Except when undergoing tests, she has continued to take levothyroxine, 100 mcg daily.
During your evaluation, she has no concerns,and examination findings are unremarkable.
Her serum concentrationsof TSH and thyroglobulin are 0.17 nIUIL and 3.9 nglmL, respectively.
The serum concentrationof thyroglobulin antibodies is 6.2IUlmL. Ultrasonography of the neck
reveals 2 structures,probably lymph nodes, 1.0 to 1.5 cm in diameter,located between the right
carotid artery and the jugular vein, about 3 cm inferior to the carotid bifurcation (level IID.
Wich one of thefollowing is the best approach now?

A. Perform a total body radioiodine scanwith measurementof the serum thyroglobulin
concentrationafter giving recombinant human TSH
B. Recommendright modified radical neck dissection
C. Increasethe levothyroxine dosageto decreasethe serum TSH concentrationto less than 0.01
mIUIL
D. Treat her with 200 mCi r3rl after stopping the levothyroxine and allowing the serum TSH
concentrationto increaseto greaterthan 30 mIUIL
E. Perform an ultrasound-guidedaspiration biopsy of the apparentright cervical "lymph nodes"
detectedby ultrasonography
145
Question
A 43-year-old man has been referred to you for follow-up after removal of 2 catecholamine-
secretingparagangliomas:a 6.5 x 4.5 x 3.5-cm urinary bladderparagangliomaand a 3.5 x 3.1 x
2.6-cm paragangliomaat the aortic bifurcation.
Preoperativelaboratory test results:

Plasmafractionated metanephrines:
Metanephrine: <0.2 nmoVl
Normetanephrine: 3I.6 nmollL
Urinary creatinine : 1242 mgl24h
Urinary dopamine : 194 pgl24 h
Urinary epinephrine:3.5 1tgl24h
Urinary metanephrine: 116 1tgl24h
Urinary norepinephrine: 2068 pgl2a h
Urinary normetanephrine: 7043 p{2a h
Urine volume: 1.9L/24h
After surgery the levels of fractionated catecholaminesand metanephrinesnormalized. You

had advised the patient that he should have testing for succinatedehydrogenase(,SDIf gene
mutations. The germline mutation testing results are now available and show that the patient has
a mutation at a splice site in SDHB (c.287-1G>C).
As you review the clinical importance of having an SDHB mutation, which one of thefollowing
statementsis correct in influencingyour discussionwith thepatient?
A. SDHB mutations are associatedwith an increasedrisk of malignant paraganglioma
B. SDHB mutations are typically associatedwith head and neck paragangliomas
C. SDHB mutations are associatedwith maternal imprinting
D. SDHB mutations are associatedwith pancreaticislet cell tumors
E. SDHB mutations are associatedwith mucocutaneousneuromas
104 E$Ap2Sro*QUE$nCIN$
146
Question
{42-year-old African American woman presentsto the emergencydepartmentwith nauseaand
vomitingof 4 days' duration.Shereportsno contactswith ill personsand has eatenno unusual
foods.On review of systems,she describesexcessivefatigue,polyuria, polydipsia,and nocturia
lastingseveralmonths.During that time shehas lost 10 pounds.
Her medicalhistory is unremarkable.Sheis taking no prescribedor over-the-counter
medications or supplements.Shehasnever usedtobaccoand statesthat shehas 1 to 2 glassesof
wineper week. Her husbandconfirmsthat shehas not beenconsumingalcohol.
Her family history is notable for type 2 diabetesmellitus in her paternal grandmotherand
father.Her father was diagnosedat age 54 years and is currently being treatedwith insulin. Her
grandmotherwas diagnosedat age 60 years, and her condition was well controlled on oral agents
until shedied of cancer.None of the patient's3 siblingshas diabetes.
On physicalexamination,blood pressureis 135/99mm Hg, heartrate is 121 beats/min,and
respiratoryrate is l8 breaths/minwith deep,laboredbreathing.Sheweighs 252 poundsand is
62inchestall (BMI : 46.1kgim'z).Sheis lethargic,but can be roused,and she is orientatedto
person,place, and time. Skin turgor is poor. Extraocular movementsare normal, and there is no
signof diabetic retinopathy in her fundi. Findings from the thyroid and pulmonary examinations
arenormal.Other than tachycardia.her cardiovascularsystemis normal. Her abdomenhas
hyperactive bowel soundsand diffuse,mild tenderness.Findings from the sensoryexamination
arenormal,and reflexes are brisk and symmetric.
Laboratorytest results from the emergencydepartment:

Sodium: 132 mBqlL
Potassium: 4.8 mEqlL
Chloride:96 mEq1L
Bicarbonate: 10 mEq/L
Serumureanitrogen: 42 mgldL
Glucose: 422 mgldL
HemoglobinAr": 12.60/o
Urinalysis: 3* glucose,"large"ketones
Whichone of thefollowing etiologies underlies this patient's ketoacidosis?

A. Type2 diabetesmellitus
B. Late-onsetautoimmunediabetesof adulthood
C. Maturity onset diabetesof the young
D. Chronicalcoholism
E. Acutealcoholinsestion
147
Question
A77-year-oldman is referredto you by his cardiologistbecauseof recentlydocumented
abnormalthyroid function test results. He was noted to have normal thyroid function 3 months
ago.Inthepastyear,the patienthas beenhospitalized3 times for brief runs of ventricular
tachyanhythmiathat developedin the setting of congestiveheart failure. He experiencedan
acutemyocardialinfarction 2 years ago. One month before the presentreferral, the patient's
prescribedamiodarone,200 mg twice daily. He hasnot had cardiacarrhythmias
cardiologist
sincetheagentwas prescribed,but he has noted nervousnessand has lost 7 pounds.His appetite
is described
as sood.
ils&p**1***LJ#sYi*f{$
105
Physical examination findings are unremarkableexcept for a slightly enlargedthyroid gland
that is firm and not tender.There are no thyroid nodules.

SerumTSH: <0.01 mIU/L
Serumtotal Tr: 160 ngldl
Thyroidal radioiodine uptake :0.9oh at 24 hours
In addilion to B-adrenergic blocker administration as tolerated, appropriate therapyfor

this
patient's problems should include which one of thefollowing?
A. Thyroidectomy
B. Antithyroid drug in maximal dosage
C. Antithyroid drug in maximal dosageand potassium iodide
D. Nonsteroidal anti-inflammatory agent4 times daily
E. High-doseprednisone
148
Question
A 3 1-year-old woman presentsfor routine follow-up of type 1 diabetesmellitus of 18 years'

duration. She has maintained good control of her glucose with hemoglobin A," values iess
than
7.2Yofor the last 10 years. She has mild, nonproliferative retinopathy, but no other chronic
complications. For the last I to 2 years,she has reported some loss of hypoglycemic recognition
and has experiencedat least I severehypoglycemic episoderequiring u..iriun"" after aday
of
high physical activity.
Medications include insulin glargine, 15 units in the morning, and insulin lispro, 1 unit per
18 g of carbohydrateand I unit per 50 mgldLcorrection with a premeal blood glucose
target of
l20mgldL.
Blood pressureis 116/7I mm Hg, and pulse rate is 68 beats/min. She is 64 inches tall and
weighs 126 pounds(BMI: 2I.6kglm'). Physicalexaminationfindings are normal other than
scatteredmicroaneurysmson an undilated funduscopic examination.

Potassium:4.1nEQL
Sodium: 138 mEq/L
Hemoglobin Ar":6.60/o
Albumin to creatinine ratio : ll ltglmgcreatinine
The following are the most recent blood glucose readings from her meter download and
are
similar to the glucose values that were downloaded from the last month.
Glucose Concentration, mg/dl

Day of Week Breakfast Lunch Dinner Bedtime
Wednesday 60 254 133 r02
Thursday 317 2rl 175 r2l
Friday 276 202 113 95
Saturday 83 r32 87 t70
Sunday 62 262 r42 123
106 ESAP2O1O-QUf;$TIONS
-
Whichone of thefollowing actions is most appropriate

now?
A. Perform a continuousglucosesensorstudy
for 6 days
B. change the carbohydratecounting ratio to l:15
g carbohydrateat breakfast
C. Increasethe insulin glarginedosageto 17
units
D' No interventionbecauseher blooJ glucose
is wel controlled
E. Changethe insulin glargine timing from
morning to evening
Question
149
422-year-old man presentsfor evaluation of hyperlipidemia

discoveredin the processof a
workup for bone infarcts. He reports that he has
been aware of a long-standing lipid disorder
for 10 years' His mother statesthat he was a
colicky baby who had difficulty breastfeeding.
wasadmittedto hospitaltwice as a child for suspected He
appendicitis,but in both instanceshe
did not have surgery when his abdominal pain
risolveO witrr observationand hydration. The
patientrelatesthe intermittentappearance
of what he calls ..rouf ,potr,,, small, yellowish
occurringin cropson his forearms.Hyperlipidemia bumps
was aiagnoieo at agel3 years,and it has
beenpersistentdespitetreatmentwith several
lipid-lowering medications.His remembersa
triglyceridemeasurementthat was 3500 mg/dl
In the last year,rte reports no specific dietaryregimen,
drinks alcohol once weekly, and
hasonly occasionalabdominalpain. Threemonths
ago, he developedpain in his lower legs
consistent with bone infarctson bone scanand CT.
He hasno history of diabetesmellitus,malabsorption,
or pancreatitis.The patient,smother is
46yeatsold, healthy,and has elevatedtotal
and HDi-cholesterol levels.His father has elevated
total cholesteroland triglyceride levels. He has
2 youngerbrotherswho are healthy. He is
currentlynot taking any medications.
on physicalexamination,he weighs 165pounds
and is 70.5 inchestall (BMI :23.3 kg/m2).
He hasno cutaneousxanthomata,and there is
no lipemia retinalis on funduscopicexamination.
He is lean with normal muscular development
and appropriatesecondarysexual characteristics.
Thereis no organomegaly,and findings from
neurologic examination are unremarkable.
Glucose:88 mg/dl
TSH = 2.6 mIIllL
HDL cholesterol: 14 mg dL
wich one of thefoltowing is the best next step in

the diagnostic evaluation and care of this
patient?
A. Measurementof lipid levels in his siblinss
B. Measurementof apolipoproteinB
C. Phenotypingof apolipoprgteinE
D' Measurementof postheparinplasma lipoprotein
lipase activity
E' Measurementof serum lipase and u-yiur. and
cr scan of the pancreas
Question
150
A 19-year-old
woman comesto your office with the chief concern
of worseninghirsutism.
Approximately2 yearsago, shebeganto notice
excessivehair growth on her face,chin. and
upper lip. Over the past year, the hair has becomemore thick and coarse.She now waxes her
face twice a week. She has also noticed thinning hair on her head, especially near the temples.
Her excessfacial hair is causing embarrassmentwith friends at school. She has become
withdrawn and has symptoms of depressionand anxiety. Her pediatrician ordered several
laboratory and radiologic studies(the results are listed below).
The patient reports normal developmentalmilestonesand menarcheat age 10 years. Her
periods have always been irregular, occurring every 3 to 4 months. Her medical history is
otherwise unremarkable.She takes no medications.On physical examination, vital signs are
stable. She is 60 inches tall and weighs 145 pounds (BMI : 28.3 kglmr). Examination of her face
reveals moderateacne and thick, dark hair on her upper lip, chin, and upper neck. you detect no
evidence of organomegalyor masseson abdominal examination. Pubertal developmentis Tanner
stage5, and examination of her external genitalia reveals minor clitoromegaly.
Laboratory test results (blood drawn in the morning during the early follicular phaseof menses):
Estradiol:40pgmL
FSH: 6.3IUIL
LH: 7.0IU/L
Progesterone: 0.5 nglmL
17-Hydroxyprogesterone: 430 ngldL
Total testosterone: 100 ngldl.
Androstenedione: 250 ng/dL
DHEA-S :252 p{dL
Pelvic ultrasonographyreveals a normal uterus and ovaries, and CT shows no abnormalities of

the abdomen,pelvis, or adrenal glands. There is no evidenceof fumors.

A. Cushing syndrome
B. Ovarian hyperthecosis
C. Adult-onset congenital adrenalhyperplasia
D. Androgen-producing neoplasm
E. Polycystic ovary syndrome
151
Question
A 2S-year-oldwoman reported a history of developing

polyuria, polydipsia, secondaryamenorrhea,and visual
field defects at age 13 years.A workup confirmed that
she had panhypopituitarism, and she was prescribed
hydrocortisone,levothyroxine, and sex steroids. She
was also treated with desmopressin,but in recent years
has required a lower dosage.Growth hormone was
prescribed for short statureand sheihas continued to
take it as an adult. She was treatedwith radiotherapy
and various medications in addition to the hormones.A
lesion was also detectedin her mastoid. Over the years,
panhypopituitarism has persisted,but she is otherwise
asymptomatic.
A sagittalview of pituitary MRI performed

before radiotherapy.
108 E$Ap2S1o-QUHSTTON$
\

A. Craniopharyngioma
B. Hypophysitis
C. Langerhanscell histiocytosis
D. Pituitary tumor
E. Breast cancer
Question
152
You are askedto seea 3l-year-old man for evaluation

of reduced libido, fatigue, hypogonadism,
andhypovitaminosis D. He presentedto his primary
care physician with a progressivedecline
in libido and reduced frequency.He has also noticed increasingfatigue
with exercise
and activities of daily lfavins
living and has recently developedaching in his long
bones and pelvis. His
initial evaluation with.his pii-ury care physician
documented-alow total testosteronelevel.
You confirm his history and obtain additional information.
He has always been thin, but
despitethe diminution in activity, his weight has
decreasedby approximately 10% of his previous
body weight. He has no history of testicular trauma
or pain.
on physical examination,he is 68 inchestall and
weighs 167pounds(BMI: 25.4kglmr).
Blood pressureis 124/83mm Hg, and heart rate is
T2 beatslmin you note normal facial hair.
Findingsfrom cardiac,pulmonary and abdominal
examinationsare normal. There is no evidence
of gynecomastia'on genitourinary examination,
he has normal testes,phallus, and pubic hair.
Hematocrit: 35.5%(microcytic anemia)
TSH: 1.02mtU/L
25-Hydroxyvitamin D : 12 nslmL
Total testosterone: t63 ng/iL
Freetestosterone: 2.I ng/dL
LH = 0.8IUIL
Prolactin : 14 nglmL
Albumin :3.6 mg/dL
Calcium:8.0 mg/dl
Alkaline phosphatase: 240 U lL
Wich one of thefoltowing would be the next appropriate

step?
A. Sendsamplefor measurementof ,,big,'prolactin
B. Screenfor tissue transglutaminaseantibodies
and total IgA
C. Measurel,2S-dihydroxyvitaminD, and pTH levels
D' Measuretestosteronesecretionin responseto
hcG chailenge
E. Order testicular biopsy
Question
153
A 23-year-oldman with a l3-year history of type

I diabetesmellitus is preparing for a
racquetballtournament.The first game of his tournament
is at g AM, and he asks for advice
abouthis insulin regimen becausehe has never
attemptedto play racquetball so early in the day
(heusuallyplays late in the afternoon).
His usualinsulindosageis 6 unitsNpH with l0 unitsinsulin
lisprowith breakfastat7
L I rAM.4
l.M)I
unitsinsulinlisprowith lunchat 12PM,and8 unitsNpH
with 12unitsinsulinlisprowith dinner
tr$&p*StS*GUffi$?t&t*$
109
at 6 PM. His last hemoglobinA," measurementwas 6.4%o,andhis fasting capillary glucose
readingat7 AM usually rangesbetween160 and 200 mgldL.
Assuming on the day of his racquetball game his 7 AM glucose concentration is in the usual
range, which one of thefollowing should he do?
A. Not take his insulin or eat breakfast,but drink 8 oz of orangejuice just before the game
B. Take his usual insulin and eat his usual breakfast
C. Omit the insulin lispro but take the usual dose of NPH with breakfast
D. Omit the NPH but take the usual dose of insulin lispro with breakfast
E. Decreasethe insulin lispro and NPH and eat his usual breakfast
154
Question
A 59-year-old woman is referred for managementof a thyroid nodule that was discovered 8
months earlier and treatedwith levothyroxine,25 mcg daily. She has no family history of thyroid
diseaseor radiation therapy. She reports no pain or tendernessin the lower anterior neck and
no dysphagia,dyspnea,or dysphonia. She is aware of the enlargementin the left lower anterior
neck, which has remained unchangedsince it was discovered.She has no symptoms that suggest
hyperthyroidism or hypothyroidism.
Medical history is notable for diabetesmellitus and hypercholesterolemia.In addition to
levothyroxine, she takes pioglitazone, 30 mg daily; glyburide, 8 mg daily; atorvastatin,20 mg
daily; and aspirin, 81 mg daily.
On physical examination,she is moderatelyobese(BMI :33kglm2). Pulse rate is92
beats/min and regular, and blood pressureis 140/88 mm Hg. Findings from the remainder of her
examination are unremarkableexcept for the thyroid gland-the right lobe feels enlargedand
indistinct while the left lobe is clearly enlarged,somewhatfirm, and measuresabout 4 x 4 x 3
cm. However, her neck is difficult to palpate becauseof obesity. She appearsclinically euthyroid.

TSH: <0.01mIU/L
SerumfreeT,:1.3 ngldL
Radioactive iodine uptake and scan and thyroid ultrasonographywere performed shortly before
she was referred to you. The radioactive iodine uptake was 32Yoat24hours; the scan showed
that most of the radioactivity was over the right lobe with some appearingas a medial shell of
tissue in the left lobe. Ultrasonography showed a2 x 2 x 3.2-cm complex left thyroid nodule
i
with 2 main components:an isoechoic,but heterogeneous,portion and a hypoechoic portion that
did not have the characteristicsof a thyroid cyst. Findings from fine-needleaspiration biopsy of
the enlargedleft thyroid lobe revealeda few clusters of small, but normal-appearing,follicular
cells, macrophages,a few atypical follicular cells, and amorphousmaterial.
Two months after stopping levothyroxine treatment, she is clinically unchanged.The
following laboratory values are obtained: serum free T,, 1.2 ngldL; serum total T., 181 ngldl-;
and serumTSH, <0.01 mIUlL.
Wich one of thefollowing would you recommendnow as definitive therapy?

A. Treatmentwith radioactive 131I
B. Observation-return in 3 to 6 months for reevaluation
C. Percutaneousultrasound-guidedalcohol ablation of the nodule
D. Treatmentwith methimazole
E. Subtotal thyroidectomy
110 ESAp2010*QUE$TI0N$
Question
155
Youareaskedto seea 37-year-old
womanto reviewthetreatmentregimen
insufficiencythatwasdiagnosedt y.u, for primaryadrenal
ugo Thepatientwantsto know what
failure'Shehadpresentedwith a 2;;;;d causedher adrenal
weighi lossand,.u"r" darkeningof rhe
patientdoesnot know the specifics skin.The
orrt.r *a*tion; however,shetells you
treatedwith hydrocortisone, that sinceshewas
shehasfelt dramaticallybetter.irr"
appeared smallon an abdominalcT scan.Although *u, told thather adrenarglands
livedin Southeast sh" .u.,"nity lives in theUnitedStates,she
Asia until agel2y"ur.. srr" ,uy. tt
performedandthat theresults;" ut ,rr" rru, periodic tuberculinskin tests
uttuy, n"gativl. Thepatienihashad
pastandsheis not anergic. allergyskin testsin the
Thirteenyearsago'.shewasdiagnosed
with Gravesdiseaseandwastreated
iodine'Thereis no familyaisto.y with radioactive
oittryJd, adrenal,o, otrro
currentlytaking 15mg of hydrocortisone disorders.she is
in.themorningunJ s"naocrine
-g in the afternoon.with regard
to hyperpigmentation, her slin is about S}%obackto r"il,"rluui rt would like this to be
studies fromI monthagoshowno.,nuir"u"rs "
::::rffi:T,lifSooratorr of glucose,
potassium,
Her current medications-include
hydrocortisone, 10 mg tablet (one
and one-half tablets in the
tabletin the afternoon);levoth
il;T::'#e-half vro*ini,7il,,.g aaly; andfludrocortisone,
on physicalexamination, BMI is 2r.7 kg/rrf,blood pressure
tateis 67 beats/min'Her skin is hyperpigmented, is l l3lg3 mm Hg, andheart
elbows,andknees).The thyroidgiurO ..p."iutty o"". ,rr" extenso*ur6"., lt ruckles,
ir-*t palpable.
To addressherpersistenthyperpigmentation,
you adviseher to increasethe afternoon
t;,13ff srthataddi
tionar
doseof
liLH:fl'ffi testingisneede
dtoaetermine
":l#jt [:i'#::;:;gge
y:;:,i:;r:#;*:jiwing woutdbethebestnexttestto estabtish
thecauseof herprimary
A. Chestradiograph
B. 2l-Hydroxylase antibodies
C. Tuberculinskin testins
D. Antiphospholipidanti6odies
E. CT-guidedadrenalbiopsy
Question
156
A 34-year-old malebodvbuilderis notedby his physician
andlargehands'His physiciant,rgg"rt, to havean unusuailyprominentjaw
heiuu" uo ro, acromegary.
reticentto havetestsperform"o;nl-.tut., "uatuatrn Thepatientis
h" is urymp,"-"ri" ,"c saysthat a family trait accounts
for hisprominentjaw andlargehands.
Nevertheless, he testingandis documented
tohaveanIGF-I concenhationof 1200
n{mL.During u"g;.;.;;
!tu"o." tolerance test,the growth
hormone leveldecreases from rg ng/mL;.time 0 t 6
glucose concentration z t ourr.His fastingbrood
is 11I mg/diatbus"tine andit reaches
";i;;ui
MRIrevealsa smallpituitarytiu"toua.noma a peakof 142 mgldLat2 hours.
with slight supra.inu,.*t"nrion, but it
comecloseto the optic chiasm. doesnot
Transsphenoidalsurgery is recommended.
Three months postoperatively,the patient,s
level is 600 ng/ml, which is elevated IGF-l
fo, hi* sex and age.His growth hormone
concentrationis
ofgrucose
andis3.5nfrmL2hours
rater.
rhepatient
is
i"i,Y#,:::ll*:llt.l:,:::,:l|:
entirelyasymptomatic. No pituiraryti-oii. ,.";;;;;;;X# #":
E$Ap201o*QUH$T|ON$
111
Wich one of thefollowing managementstrategies would you recommendnow?
A. Somatostatinanalogue
B. Another transsphenoidalsurgery
C. Watchful waiting
D. Gamma knife radiotherapy
E. Pesvisomant
157
Question
A 59-year-old man with gallbladder diseasehas developedsepsissyndrome and is admitted

to the intensive care unit. He is treatedwith volume expansionand a systemic antibiotic. The
first72 hours of his admission are complicated by borderline-low mean arterial pressureand
radiologic evidenceof pulmonary vascular congestion.Hypothyroidism was thought to be
present 10 years earlier and thyroid hormone replacementwas initiated at that time. Therapy
lapsed and the patient has had no replacementthyroid hormone therapy for severalyears. He
remains alert and reports no classic symptoms of hypothyroidism. You are askedto seethis
patient becauseof abnormal serum thyroid function test results.
On physical examination in the intensive care unit on the third hospital day, this overweight,
slightly icteric man has a blood pressureof 104160mm Hg and a heart rate of 100 beats/min.
His body temperatureis 97"F.An intravenousline is in place. He is comfortable sitting in bed
at a 30-degreeangle, but has 2-cm neck vein distention that fills from below. Auscultation of
the lungs reveals bibasilar rales on inspiration. Heart soundsare distant. There is no peripheral
edema.Deep tendon reflexes are 1* at the ankles and relaxation phaseis normal.

SerumTSH:0.1 mIU/L
Serumfree To: 1.1 ngldl,
Serumtotal Tr:50 ngldl.
Random serumcortisol:58 pgldl-
Blood cultures are positive for a gram-negativebacillus on day 2 of hospitalization. The

intensivist managing the patient's care suspectsthe patient has hypopituitary hypothyroidism, in
addition to sepsis.
lVhich one of thefollowing options is your recommendqtion?

A. Start levothyroxine, 100 mcg daily
B . Start liothyronine (Tr), 50 mcg daily
C . Start levothyroxine at a dosageof 25 mcg daily; order MRI of the brain (hypothalamus,
pituitary)
D. Perform repeatedmeasurementsof serum TSH and T, at regular intervals during the course
ofrecovery from the underlying condition (sepsis)
E. Startmethimazole,l0 mg daily
158
Question
A 75-year-old man with osteopenianoted on routine chest x-ray has a bone mineral density
assessment.He has no family history of osteoporosisand no personalhistory of bone fracfures.
In the past, he drank at least 3 glassesof milk daily, but has decreasedthis intake becauseof mild
lactoseintolerance.He does not take calcium supplements,but takes a multivitamin daily. He
112 ESApzt)1o*QUE$?roN$
\
hasneverusedglucocorticoids.He lives with his wife and usesa cane.He has hypertensionand
coronaryartery diseaseand had 3-vesselheart bypass surgery at age60 years. Social history is
notablefor quitting smoking and refraining from alcohol consumption after his bypass.
His DXAresults are shown:
Area, BMC, BMD,

2
Resion cm s slcm2 T score Z score
LI t 5.06 17.66 t . 1 7 3 1.5 2.4
L2 1 5 . 9 1 1 9 . 9 1 1.25I 1.4 2.5
L3 16.29 21.33 1 . 3 1 0 1.9 2.9
L4 t 8.49 22.21 1.201 (r.l t.6
Total 65.75 8 l . 1 2 t.234 1.3 2.3
Area, BMC, BMD,

Resion cm' Q slcmz T score Z score
Neck 5.60 3.44 0.614 L.-) 1.0
Troch tt.46 8.24 o.719 -0.5 -0.1
Inter 24.36 2 7 . 5 8 l.132 -0.3 -0.4
Total 4t.41 39.26 0.948 -0.6 -0.2
Ward's r . t 7 0.48 0.408 an -0.6
Area, BMC, BMD,

2
Radius cm a alcmr T score Z score
LID 4.54 1.60 o.352 -3.3 -1.8
MID 10.55 5.47 0.519 -3.5 -2.4
Lt5 3.37 2.16 0.640 -3.3 -L.7
Total l8.46 9.23 0.500 -3.6 - La
. t t
gsr{3**[jffi$Tfss{$
H$"ep 113
After reviewing the DXA scans,which one of thefoilowing
shourdyou tert him?
A. He has osteoporosison the basis of T:score
criteria
B. He has low bone density (osteopenia)on the
basis of r:score criteria
C. The bone density at the spine is normal
D' The World Health organization osteoporosis
classification cannot be used in men
E' Before deciding on therapy,you would like
to do another bone mineral density assessmentin
I year
Question
159
A 52-year-oldman with a 7 -yen historyof type2 diabetes

mellituspresentsfor routinefollow-
up' He wasdiagnosedwith diabetesduringan evaluation
of backpainwhente wasincidentally
documented to havea fastingglucoseconcentratio
n of 212 mg/dL.Hehadnot seena physician
for at least5 yearsbeforethatvisit. other medicalproblems
ttut *.r" identifiedat the same
time includedhypertension andmild hypertriglyceridemia,alongwith a slightly low HDL-
cholesterollevel andan LDl-cholesteiol reveror D3
mgldLthatwasappropriatelytreatedwith
a statin'He hasno known complicationsof diabet.r,
unih" is asymptomatic. He hu, no family
historyof earlyheartdisease,althoughhis fatherhad
hypercholesterolemia and hypertension and
experienced a myocardialinfarctionat age73 years.
Medicationsincludemetformin,1000mg trvicedaily; glipizide
extendedrelease,l0 mg
dailv; simvastatin,20 mgdailv; aspirin,8l mg dairy;and "^"'
Jn i;oi id;;;i;.
on physicalexamination,bloodpr"r*"ir_ if;olsz-*
rrg, pulserateis 74 beats/min,and
BMI is 33 kglm2'Findingsfrom undilatedophthalmolog;;;;;ination
Thyroidexaminationfindingsarenormal.on examinat6n indicateno retinopathy.
of the extremities,legsarewithout
edema'andfeet arewithout lesionsandhavenormal
vibratoryandmonofilamentsensation. The
restof the examinationfindingsarenormal.
l LDL cholesterol:107mgldL
ll HDL cholesterol: 3g mg/dl
Hemoglobin
i A,":7.2o/o
Spoturine for aibumin:22 pg/mgcreatinine
I
l
t Electrolytes'serumcreatinine,andliver enzymes
findingsarenormal.
areall normal.Restingelectrocardiogram
I
I Todaythepatientstatesthathe is planningto change
I his habitsto improvehis diabetes
controlandoverallhealth.He askswhat elseshould
il
I
beginsexercise.
be donebeforehe changeshis diet and
il
Iil wich one of theforowing is the mostappropriate
adviceyou can offer?
]I A. Begin a low-carbohydrate, ketogenicdiet andbegin r-hour workouts6 daysa
I'| week
B' Increasethe simvastatindosagelo40 mgdaily,
seethe diabetesnutritionist,andbeginan
I _
exerciseprogramwithslowprogression, at least5 daysa week
I c' Do a routinetreadmillstresselectrocardiogram
testand.t uog. the simvastatinto
tI atorvastatin,
40 mg daily
D' completea stressmyocardialperfusionimaging
ffi diabetesandotherrisk factors
E' completea stressechocardiogram
testbeforedoingany exercisebecauseof
becausethis will showadditionalinformationabout

cardiacfunctionalstatusbeforehe beginsexercise his
114 ESAP201o*QUESTTONS
r
El
Zt
-,
-
Question16o -
fIft.
-.
E:
I A 36-year-oldwomanpresentsfor management
diagnosed of t)?e I diabetesmellitus.Shewas
X 18yearsagoandhassincebee]r originally
on t;"ir;;";,ilin r"gi-.ns. she hasnonproliferative
retinopathythat hasbeenstable
3 over severalyearsof follo**p.
takesoralcontraceptives she is otherwisehealthyand
G andmultiviraminr.i{".il;;;'.t
hypercholesterolemia ptyri"iun rru.t i.a treatingher
3, with pravastatinandatorvastatin,
myalgias'Shedoesn9!smokecigarettes ilorn .uur"j inJupacitating
G or drink alcoholuio"i*rri.r,
rono*,
hada myocardialinfarcti;n ui ug. no dietaryrestrictions.Her
63 years,and a matemaluncle died
x fr*::t suddenty at age52
G Onphysicalexamination,sheis
64.5inchestall andweighs125pounds
Herbloodp**T:^ti 'u1',' t*ttfi (BMI = 21.1kg/mr).
G Thereis no goiro ri-noing,from
arenorrnal'Thereis noI abdominal her cardiacexamination
s;' tldemes: d;;;*olrno."guty.
edema' andpinprick andvibratoryrrorution "r she hasno peripheral
II in the feet areintact.
t*,fr*"'*lli'Iro,
$ Triglycerides
= 110mgdl
mg/dL
E
H_DL cholesterol: 54mgdL
I
LDL cholesterol: 127ig/dl_
D -
G _HemoglobinA,"=7.g%o
f Yd_ou.yalbuminto creatinineratio: tl pg/mg
TSH: l.l mrU/L
$
Addingwhich one of thefoilowing
c is the bestnextstepin the care of
thispatient?
$ A. Fenofibrare
I A. Simvasratin
I C. Fishoil
I D. Gemfibrozil
[: E. Niacin
il
v
ESAP2010-QUESTTONS
115

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1

{23-year-old woman with a history of a multinodular goiter had a

Laboratory test results from the emergencydepartment:

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Llthichone of thefollowing should you do now?

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Axial CT imageof the adrenalglands

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