Download VRAGEN SCHILDKLIER 104] A 75-year

VRAGEN SCHILDKLIER
104] A 75-year-old woman is admitted to the medical intensive care unit with progressive
obtundation. Physical examination reveals a nonarousable elderly women, with core
temperature of 35 °C (95 °F), blood pressure of 104/84 mm Hg, and pulse rate of 48/min, The
patient weighs 82 kg (180 lb), and has a 4-cm transverse scar above the suprasternal notch,
cold doughy skin, and delayed deep tendon reflex relaxation phase. The patient's medical
records state that she is taking both digoxin and levothyroxine, but she has not been seen in
more than a year. Serum sodium is 127 meq/L (127 mmol/L); total cholesterol is 318 mg/dL
(8.22 mmol/L). Digoxin is undetectable. Serum thyroid-stimulating hormone level is pending.
Urinalysis shows too many leukocytes to count and gram-negative rods. Urine and blood
cultures are pending.
Which of the following would be appropriate therapy at this time?
A
Levothyroxine, corticosteroids, empiric antibiotics
B
Levothyroxine alone
C
Levothyroxine and liothyronine
D
No therapy until TSH level is known
116] A 65-year-old man is hospitalized for treatment of severe hypothyroidism. He was doing
well initially on thyroid hormone replacement therapy but experienced a syncopal episode
when walking to the bathroom. The patient denies palpitations or chest pain.
On physical examination, the blood pressure is 80/60 mm Hg, and the pulse rate is 72/min. He
has jugular venous distension, diminished heart sounds, and a palpable liver edge below the
right costal margin. Complete blood count and electrolytes are normal. Serum free T4 is 0.7
ng/dL (8.5 pmol/L) and serum TSH is 22 µU/mL (22 mU/L). Electrocardiography shows low
voltage in all leads. Chest radiograph shows an enlarged cardiac silhouette.
Which of the following is the most likely cause of this patient's change in clinical status?
A
Adrenal insufficiency
B
Ischemia
C
Myocarditis
D
Cardiomyopathy
E
Cardiac tamponade
2] A 67-year-old man is evaluated for palpitations, heat intolerance, and a 2.4-kg (5-lb)
weight loss over 1 month. The patient has a history of dilated cardiomyopathy and congestive
heart failure, and his medications include warfarin, digoxin, lisinopril, and carvedilol. On
physical examination, the pulse is 82/min and regular, the thyroid gland is twice normal size,
and he has a moderate resting tremor. Laboratory testing shows free T4 3.1 ng/dL (39.7
pmol/L) and serum thyroid-stimulating hormone <0.01 µU/mL (0.01 mU/L).
Which of the following changes in his therapeutic regimen should be made while he remains
thyrotoxic?
A
Decrease both warfarin and digoxin doses
B
Increase both warfarin and digoxin doses
C
Increase warfarin dose, decrease digoxin dose
D
Decrease warfarin dose, increase digoxin dose
E
No change in warfarin or digoxin dose
29] A 27-year-old woman is evaluated for palpitations and heat intolerance that develop 3
months after a successful pregnancy. She is breastfeeding. The patient's older sister has
Graves' disease, but the patient herself has no history of thyroid disease.
On physical examination, the blood pressure is 128/70 mm Hg, and the pulse rate is 104/min.
Eye examination reveals stare and lid lag, but no proptosis. The thyroid gland is moderately
enlarged and nontender. She has moist palms and brisk deep tendon reflexes. Serum free T4 is
2.7 ng/dL (34.2 pmol/L), free T3 46.22 ng/dL (7.1 pmol/L), and thyroid-stimulating hormone
(TSH) is undetectable.
Which one of the following is the most appropriate next step in this patient's management?
A
Serum anti-thyroid peroxidase antibodies
B
Serum thyroglobulin level
C
Serum TSH immunoglobulins
D
An empiric trial of antithyroid drugs
E
Radioiodine (I-131) uptake and thyroid sca
82] A 21-year-old man is evaluated for gynecomastia of 2 month's duration. He has also lost
4.5 kg (10 lb) and has difficulty sleeping. On physical examination, the blood pressure is
147/76 mm Hg and the pulse rate is 92/min. He has lid lag, diffuse goiter, bilateral
gynecomastia, and brisk deep tendon reflexes. Laboratory testing shows free T4 9.9 ng/dL
(128 pmol/L), TSH <0.01 µU/mL (0.01 mU/L), total T3 27.34 ng/mL (4.2 nmol/L), negative
thyroid stimulating immunoglobulins, antithyroid peroxidase antibodies <2 U/L, estradiol 124
pg/mL (455.2 pmol/L), and total testosterone 305 ng/dL (10.6 nmol/L). Qualitative hCG
testing is reported as “positive.”
What is the most likely cause of this patient's thyrotoxicosis?
A
Graves' disease
B
Silent thyroiditis
C
A testicular tumor
D
An activating mutation of the TSH-receptor
E
Marijuana use
102] A 35-year-old man is evaluated for palpitations and difficulty sleeping. He has no eye
symptoms or neck pain. The patient has chronic hepatitis C and 3 months ago began
interferon alfa therapy. He is a nonsmoker, and family history is significant only for a mother
with hypothyroidism.
On physical examination, the blood pressure is 135/75 mm Hg, and the pulse rate is 95/min.
Thyroid examination reveals a 25-g goiter without tenderness, nodules, or bruit. Serum
thyroid-stimulating hormone is <0.01 µU/mL (0.01 mU/L), free T4 2.7 ng/dL (34.7 pmol/ L),
and antithyroid peroxidase antibody titer 180 U/mL (normal <2 U/mL). Radioactive iodine
uptake is 0.6% at 24 hours. Thyroid ultrasonography reveals a diffusely heterogeneous
thyroid parenchyma, but no nodules. Doppler flow is diminished over the thyroid bed.
Interferon alfa therapy is stopped by his hepatologist.
Which of the following is the most appropriate therapy for this patient's thyrotoxicosis?
A
Methimazole
B
Radioiodine ablation therapy
C
Prednisone
D
Atenolol
E
Near-total thyroidectomy
114] An 82-year-old woman with a history of Hashimoto's thyroiditis is evaluated for a
rapidly expanding thyroid mass and progressive dysphagia and dyspnea. She has lost 2.2 kg
(5 lb) over the preceding 6 weeks. On physical examination, the blood pressure is 118/78 mm
Hg, and the pulse rate is 86/min. Thyroid examination reveals a firm 5-cm left thyroid mass
that moves poorly with swallowing. Respiratory stridor is evident. Fine needle aspiration of
the mass shows numerous uniform lymphocytes. CT scan of the neck shows the thyroid to
completely encircle the trachea.
Which of the following is the most likely diagnosis?
A
Medullary thyroid cancer
B
Anaplastic thyroid cancer
C
Thyroid hemorrhage
D
Thyroid lymphoma
E
Laryngeal cancer
78] An 82-year-old woman with a history of Hashimoto's thyroiditis is evaluated for a rapidly
expanding thyroid mass and progressive dysphagia and dyspnea. She has lost 2.2 kg (5 lb)
over the preceding 6 weeks. On physical examination, the blood pressure is 118/78 mm Hg,
and the pulse rate is 86/min. Thyroid examination reveals a firm 5-cm left thyroid mass that
moves poorly with swallowing. Respiratory stridor is evident. Fine needle aspiration of the
mass shows numerous uniform lymphocytes. CT scan of the neck shows the thyroid to
completely encircle the trachea.
Which of the following is the most likely diagnosis?
A
Medullary thyroid cancer
B
Anaplastic thyroid cancer
C
Thyroid hemorrhage
D
Thyroid lymphoma
E
Laryngeal cancer
57] A 26-year-old woman is evaluated for amenorrhea. Her last menstrual period was 3
months ago, and three home pregnancy tests have been negative. She states that she has no
other symptoms and takes no medications. Menarche occurred at age 12 years, and her
menstrual cycle has been regular until 3 months ago. Upon further questioning, she recounts
weekly headaches and occasional galactorrhea on breast palpation. Physical examination,
including neurological examination, is normal. Deep tendon reflexes are normal. Serum
prolactin level is 1665 ng/mL (1665 mg/L).
Which of the following is the most likely cause of this patient's hyperprolactinemia?
A
Pregnancy
B
Cirrhosis
C
Primary hypothyroidism
D
Prolactin-producing pituitary tumor
60] A 33-year-old woman is evaluated for frontal headache and blurry vision. She has
previously been in good health, but has not experienced menses in the preceding 2 months.
On physical examination, the pulse rate is 58/min. Pupil reactivity and eye movements are
normal, and she has a bitemporal hemianopsia. Breast examination is notable for expressible
galactorrhea. Skin is cold and doughy in texture, and deep tendon reflex relaxation phase is
prolonged. Laboratory testing reveals a prolactin level of 85 ng/mL (85 mg/L), a TSH of 80
µU/mL (80 mU/L), and a free T4 of less than 0.3 ng/dL (4.0 pmol/L). Urine hCG is negative
for pregnancy. An MRI of the sella turcica shows an enlarged pituitary gland that abuts the
optic chiasm.
Which of the following is the most appropriate therapeutic approach to this patient?
A
Transsphenoidal surgery
B
Bromocriptine
C
Octreotide
D
Levothyroxine
E
Gamma knife pituitary irradiation
67] A 45-year-old woman is evaluated for malaise, fatigue, and a 4-kg (8.8-lb) weight loss.
She has no nausea, vomiting, or diarrhea. The patient has autoimmune thyroiditis and takes
levothyroxine, 0.1 mg daily. Six months ago, her serum free T4 was 1.3 ng/dL (17.1 pmol/L)
and thyroid-stimulating hormone (TSH) was 1.9 µU/mL (1.9 mU/L).
On physical examination, the blood pressure is 98/60 mm Hg and the pulse rate is 88/min,
with orthostatic changes. Thyroid examination shows a firm, 25-g thyroid without nodules.
Cardiovascular and pulmonary examinations are normal. Skin examination shows increased
pigmentation over an old appendectomy scar. Deep tendon reflexes are normal. Laboratory
testing is notable for serum potassium of 5.9 meq/L (5.9 mmol/L), calcium 10.4 mg/dL (2.59
mmol/L), free T4 1.4 ng/dL (18.1 pmol/L), and serum TSH 8.3 µU/mL (8.3 mU/L).
Which of the following is the most likely cause of this patient's symptoms?
A
Insufficient thyroid hormone therapy
B
Antacid abuse
C
Dysautonomia
D
Addison's disease
E
Pernicious anemia
125] A 38-year-old woman is evaluated for persistent serum thyroid-stimulating hormone
(TSH) elevation despite gradually increasing doses of levothyroxine therapy. She was
diagnosed with Hashimoto's thyroiditis 1 year ago, but has never achieved euthyroidism,
despite serial increases in her levothyroxine dose, currently at 0.4 mg daily. Her only
symptoms are fatigue and intermittent abdominal bloating. She has no change in weight or
diarrhea. She is compliant with therapy and does not take calcium, iron, or antacids
concurrently with levothyroxine. She has no history of gastrointestinal resection or psychiatric
disturbance. Pill counting confirms an appropriate usage during the course of her latest
prescription.
On physical examination, the blood pressure is 116/84 mm Hg, and pulse rate is 56/min; she
weighs 58 kg (127 lb). The patient has lateral thinning of the eyebrows and deep tendon
reflexes are minimally delayed. Laboratory testing shows free T4 of 0.6 ng/dL (7.2 pmol/L)
and TSH of 22 µU/mL (22 mU/L).
Which of the following is the most likely explanation for the patient's clinical status?
A
Noncompliance
B
Congenital resistance to thyroid hormone
C
Celiac disease
D
Resistance to TSH
E
Selective malabsorption of levothyroxine
72] A 42-year-old man is found to have primary aldosteronism during evaluation of
hypokalemia and hypertension. His plasma aldosterone/plasma renin ratio is 32, with a
plasma aldosterone concentration of 20 ng/dL (554.8 pmol/L). A normal saline infusion test
reveals a plasma aldosterone level of 18 ng/dL (499.32 pmol/L) and a plasma renin activity of
<0.6 ng/h/mL (0.6 µg/h/L).
Selective adrenal venous sampling fails to reveal a gradient between the adrenal glands. The
diagnosis of bilateral adrenal hyperplasia is made, and therapy is initiated with
spironolactone.
The patient's blood pressure normalizes and he discontinues potassium supplementation;
however, he develops painful gynecomastia.
Which of the following is the most appropriate next step in the management of this patient?
A
Substitute lisinopril for spironolactone
B
Karyotype to exclude Klinefelter's syndrome
C
Referral to surgery for bilateral adrenal resection
D
Substitute eplerenone for spironolactone
E
Breast reduction surgery