09-27-2007, 05:17 AM
A 48-year-old man comes to the clinic with symptoms of sexual dysfunction. He states that for the last year and a half, he has had a markedly decreased libido and trouble maintaining an erection. He has also occasionally noticed some milky-type of discharge from his nipples. He denies headaches, shortness of breath, or chest pain. He has had no abdominal or urinary symptoms. He has no significant past medical history and takes no medications. On physical examination, he is afebrile and has normal vital signs. His visual acuity, visual fields, extraocular movements, and pupillary response to light are normal. Remainder of neurologic examination is normal. Laboratory studies show a leukocyte count of 5,600/mm3, hematocrit 45%, platelets 230,000/mm3, glucose 100 mg/dL, creatinine 0.8 mg/dl, blood urea nitrogen 16 mg/dl, serum prolactin 1,000 ng/ml (normal <20 ng/ml). The next most appropriate step in management is A. bromocriptine
B. mammography
C. a MRI of the brain
D. a MRI of the lumbar spine
E. sildenafil citrate
Explanation: The correct answer is C. This patient has impotence, loss of libido, and galactorrhea related to hyperprolactinemia. The most common cause of this in men is probably medication induced, however, he is on no medications. The next main thing to rule out is a prolactin secreting microadenoma by an MRI of the brain.Bromocriptine (choice A) may end up being the treatment of choice for this patient if a microadenoma is found. However the diagnosis should be made prior to treatment. If bromocriptine therapy fails to relieve symptoms, or if the adenoma grows/begins causing other symptoms, referral to neurosurgery to evaluate for transphenoidal resection would be warranted.There is no indication for a mammogram (choice B) or an MRI of the lumbar spine (choice D) in this case.Sildenafil (choice E) also may end up being helpful in this case for the patient's symptoms. However, again making the underlying diagnosis is the most appropriate first step in the work up.
A 23-year-old woman comes to the clinic for a pre-employment examination. She recently moved to the area from out of state and got a job at a local small business. Her past medical history is significant only for diabetes mellitus type I, which she has had since age 13. Her only medication is insulin, which is infused via an insulin pump. She denies smoking or using illicit drugs. She admits to social alcohol consumption less than once a week and says she runs 2 miles daily. She is not sexually active. You perform a full physical examination. Her temperature is 37.1 (98.8 F), blood pressure is 136/89 mm Hg, pulse is 54/min, and respirations are 12/min. Her skin is warm and dry. Cardiovascular examination reveals a normal S1, S2 with no murmurs appreciated. Respirations are equal bilaterally without any abnormal breath sounds. Extremities show no clubbing, cyanosis, or edema. Strength is equal bilaterally and sensation is full throughout. The patient exhibits normal reflexes. She returns to the clinic several more times and her blood pressure remains elevated. The most appropriate initial pharmacotherapy for this patient is A. amlodipine
B. atenolol
C. enalapril
D. furosemide
E. hydrochlorothiazide
Explanation: The correct answer is C. This patient is a type I diabetic with mild hypertension. The Joint National Committee recommends ACE inhibitors, such as enalapril, as first-line treatment of hypertension in diabetics. Multiple studies have proven that ACE inhibitors prevent microalbuminuria and thus preserve renal function. Amlodipine (choice A) is a calcium channel blocker commonly prescribed for hypertension. However, it has not been proven to have the renal protective properties of ACE inhibitors. Therefore, choosing amlodipine is incorrect.Atenolol (choice B) is a beta-blocker that is often used as a first-line agent in non-diabetics. However, beta-blockers should be avoided in patients with type I diabetes, asthma, and depression. Additionally, the patient's low heart rate would contraindicate the use of a beta-blocker.Furosemide (choice D) and hydrochlorothiazide (choice E), a thiazide diuretic and a loop diuretic, are often used as initial agents in the treatment of hypertension due to their efficacy and cost effectiveness. However, the renal protective benefits of an ACE inhibitor make enalapril a more appropriate choice for this patient.
A 37-year-old accountant is hospitalized for a laparoscopic cholecystectomy. The day after his surgery, he reports feeling palpitations in his chest. He says that even prior to his hospitalization he had been feeling nervous and has noticed himself perspiring more easily. His past medical history is significant for a resection of a benign brain tumor during childhood. He also mentions that he may have lost weight, although he has not been dieting. Physical examination reveals a thin, anxious appearing male. His lungs are clear and cardiac auscultation demonstrates an irregularly irregular rhythm and no murmurs. Neurologic examination is significant for a fine tremor in both hands. An electrocardiogram performed at the bedside shows atrial fibrillation. The most appropriate study at this time to evaluate this patient's symptoms is A. a chest x-ray
B. a CT scan of the head
C. an exercise tolerance test
D. a serum thyroid stimulating hormone
E. a ventilation/perfusion scan
Explanation: The correct answer is D. Nervousness, tremor, heat intolerance, and weight loss are classic signs and symptoms of hyperthyroidism. Hyperthyroidism is a well known cause of atrial fibrillation. This arrhythmia will respond to the treatment of the underlying endocrine abnormality. A serum thyroid stimulating hormone (TSH) level will be abnormally low in patients with hyperthyroidism and is a very specific test for this disorder.A chest x-ray (choice A) is not a useful study in the evaluation of atrial fibrillation in the setting of hyperthyroidism. There is no reason to suspect other primary lung diseases in an otherwise healthy young male to warrant a chest x-ray.A CT of the head (choice B) will not provide information about the etiology of the patient's atrial fibrillation. He has a distant history of surgical resection of a benign brain tumor and there is no reason to suspect metastatic disease. There is no association between primary brain pathology and atrial fibrillation.An exercise tolerance test (choice C) is an examination to evaluate for cardiac ischemia or past infarct. This study is performed by having a patient exercise on a treadmill while wearing the electrocardiogram leads. A continuous EKG is performed during exercise to monitor for signs of ischemia. Cardiac ischemia is a very common cause of atrial fibrillation. However, there is no reason to suspect an ischemic etiology of this arrhythmia in a young, otherwise healthy patient.A ventilation/perfusion scan (choice E) is a good diagnostic study for the evaluation of a pulmonary embolism. A pulmonary embolism is a known cause of atrial fibrillation. Although recent surgery and hospitalization does put the patient at increased risk for thromboembolic disease, he does not have shortness of breath, chest pain, or other classic symptoms of a pulmonary embolism. Young and healthy patients do develop thromboembolic disease in the setting of pelvic and lower extremity trauma, and prolonged hospitalization or bedrest.
A 20-year-old college student is brought to the emergency department by his girlfriend because of the sudden onset of a headache, shaking, sweating, and blurry vision. She says that he became very confused during the taxicab ride over to the hospital, asking, "where are you taking me to, the airport?" He was fully aware that they were going to the hospital as they left their apartment 5 minutes earlier. These symptoms started as they were lying in bed going to sleep, 3 hours after coming back from the local Italian restaurant, where they both ate fettucine alfredo. They did not drink any alcohol tonight. He has had similar, but milder, symptoms on four previous occasions in the past few years. He has no other medical conditions and does not take any medications. His temperature is 37.0 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 22/min. He is not oriented to person, place, or time. He begins to lose consciousness during the physical examination, which is otherwise unremarkable. At this time the most appropriate conclusion is: A. He should drink a glass of orange juice immediately
B. An intravenous bolus of glucose as a 50 % solution should be given immediately
C. An intravenous bolus of isotonic saline should be given immediately
D. Naloxone, given intravenously every 2 minutes, will reverse this patient's symptoms
E. Physostigmine, given intravenously over 2 minutes, will reverse this patient's symptoms
Explanation: The correct answer is B. This patient is most likely experiencing the symptoms of hypoglycemia, which should be treated with intravenous glucose until the patient can eat a meal. There are two categories of symptoms associated with hypoglycemia: the autonomic response and the neuroglycopenic response. The former is due to excessive secretion of epinephrine/norepinephrine and consists of tremor, palpitations, sweating, hunger, and anxiety. The latter is caused by central nervous system dysfunction and includes dizziness, headache, blurry vision, confusion, abnormal behavior, and a loss of consciousness. Symptoms do not usually occur until the blood glucose falls below 45 mg/dL. Causes of hypoglycemia include postprandial hypoglycemia, fasting hypoglycemia, insulinomas, and factitious hypoglycemia. This patient should not have a glass of orange juice (choice A) right now because he is losing consciousness and therefore cannot eat or drink. The initial treatment for hypoglycemia with both autonomic and neuroglycopenic symptoms is intravenous glucose. This can be discontinued when the patient is able to eat and drink.Administration of isotonic saline, intravenously (choice C) is part of the initial treatment for diabetic ketoacidosis. 5% glucose solutions should be added when the plasma glucose level falls below 300 mg/dL. This would be inappropriate for a hypoglycemic because they need glucose. The symptoms of DKA include increased urination, thirst, abdominal pain, mental status changes, anorexia, nausea, and vomiting. The patient in this case does not have these symptoms.Naloxone would reverse this patient's symptoms (choice D) if they were caused by an opioid overdose, not hypoglycemia. Naloxone is an opioid antagonist that competes for the opioid receptors and will block the effects of heroin and other opioids. Symptoms of an opioid overdose include miosis, respiratory depression, coma, hypotension, and bradycardia. The patient in this case does not have these symptoms.Physostigmine would reverse this patient's symptoms (choice E) if they were caused by anticholinergic poisoning, not hypoglycemia. The symptoms of anticholinergic poisoning can occur with overdoses of antihistamines, atropine, tricyclic antidepressants, and scopolamine, and include hyperthermia, vasodilatation, decreased salivation, mydriasis, delirium, and hallucinations. The girlfriend did not say that he took any medications. The fact that these symptoms occurred a few hours after a meal and that he has had similar episodes in the past and his physical examination did not reveal mydriasis or hyperthermia makes his condition more consistent with hypoglycemia than anticholinergic poisoning.
A 29-year-old woman comes to the office because of a 12-pound weight gain in the past 3 months. She does not seem to think that it is related to a change in appetite. She has no chronic medical conditions and takes no medications. She exercises regularly and drinks a glass of wine with dinner each night. She says that she usually only eats foods that are labeled "low-fat" or "fat free." She has recently moved to your town to live with her fiancee and just started working as a kindergarten teacher. She enjoys her job and is very happy in her new home and with her fiancee. She is 168 cm (5 ft 6 in) tall and weighs 67 kg (148 lb). Her blood pressure is 135/90 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination is unremarkable. She is picking her cuticles and tapping her feet during the history and examination. The most appropriate next step is to A. ask her if she recently quit smoking
B. determine thyroid stimulating hormone levels
C. order a biochemical profile
D. order a dexamethasone suppression test
E. refer her to a nutritionist
Explanation: The correct answer is A. In the evaluation of weight gain, the first step is to perform a thorough history and physical examination. If the patient tells you that they have not really had a change in appetite and have had a recent weight gain, you need to ask about medications, such as tricyclics, steroids, and antipsychotics and about smoking cessation and psychiatric disorders. This patient appears fidgety, which may be consistent with smoking cessation. Smoking cessation is often associated with a small weight gain (5-10 lbs), but it can lead to more dramatic weight gain in others. Before you perform any expensive and unnecessary diagnostic studies, you should first perform a detailed history.Determining thyroid stimulating hormone levels (choice B) is appropriate in the evaluation of weight gain if there is a negative drug history, no recent smoking cessation, and a normal biochemical profile. Since hypothyroidism is part of the differential diagnosis for weight gain, you should consider it early in the work-up, but a biochemical profile should be performed first.The initial work-up for weight gain is a detailed history, including medication and drug use and recent smoking cessation. If those are negative, then a biochemical profile (choice C) is indicated. A biochemical profile may indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes will most likely lead to an elevated glucose, while Cushings is sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis, hyperglycemia, and hypercholesterolemia.A dexamethasone suppression test (choice D) is part of the initial evaluation of Cushing syndrome. You should first perform a complete history and if negative for such things as drug history, recent smoking cessation, and a psychiatric disorder, you should then order a biochemical profile. A dexamethasone suppression test should be ordered if the biochemical profile is suspicious for Cushing syndrome (hypokalemia, hypochloremia, metabolic alkalosis, hypercholesterolemia, and hyperglycemia).Referring her to a nutritionist (choice E) is inappropriate at this time. The case says that the patient has had weight gain with no change in appetite or eating habits. She requires a thorough history and examination, and if negative, an evaluation for a medical condition such as Cushing syndrome, diabetes mellitus, thyroid disease (even though this is usually associated with a poor appetite), and fluid overload. A nutritionist may be valuable later if the complete evaluation is negative and you determine that she has poor eating habits. Obviously in that case you should try to help her with her dietary habits, but if you are unsuccessful, a nutritionist may be helpful.
A 44-year-old obese woman comes to the clinic for a routine follow up visit for diabetes. Her diabetes has been poorly controlled in the past year and her hemoglobin A1c level was last at 11%. She denies any new problems with her health. On physical examination, you note firm, non-pitting induration on her upper back with a clear cut-off border. Within the indurated areas there are small papules resembling follicular prominences. Under her breasts are beefy-red patches in the moist areas with satellite lesions. On her left pretibial area, there is a dusky-red elevated plaque with a sharply circumscribed border. There is an orange-hue to this lesion, and the center of the lesion is flattened and atrophic. In the order of these descriptions, the cutaneous manifestations of diabetes that this patient has are A. scleredema, candidiasis, necrobiosis lipoidal diabeticorum
B. scleredema, candidiasis, stasis dermatitis
C. scleredema, tinea corporis, stasis dermatitis
D. scleroderma, candidiasis, necrobiosis lipoidal diabeticorum
E. scleroderma, tinea corporis, stasis dermatitis
Explanation: The correct answer is A. Scleredema, candidiasis, necrobiosis lipoidal diabeticorum (NLD) is correct, because these three are all commonly associated with diabetes. Scleredema is a connective disorder with sudden onset of marked, nonpitting, symmetric induration of the posterior and lateral aspects of the neck spreading to shoulders, upper back, and proximal arms. The indurations are of wood-like consistency. Erythematous papular eruption occurs during the early stage of the disease. A syndrome has been recognized consisting of scleredema of long duration, obesity, maturity onset, latent or overt diabetes, and high incidence of cardiovascular disease. Candida albicans flourishes in the recesses created by redundant skin folds. Exacerbating factors may include diabetes mellitus, systemic medications, nutritional factors, and diminished salivary function. NLD is relatively asymptomatic, and is characteristically found on the anterior and lateral lower legs. They may also be present on the face, arms, and trunk. They begin as small, red nodules that enlarge to a plaque with irregular, flattened and eventually depressed atrophy. NLD seems to be a marker for diabetes.Stasis dermatitis (choice B) is incorrect because classical stasis dermatitis appears on the medial surface of lower extremities with hyperpigmented patches mixed with occasional erythematous plaques. Often times, one can appreciate tortuous enlarged varicose veins.Tinea corporis (choice C) is incorrect because it generally presents with erythematous annular plaques, with central clearing and no satellite lesions.Scleroderma (choice D) and (choice E) is incorrect, because this is a connective disorder associated with the tightening of the skin, difficulty swallowing, telangiectasia, calcinosis, sclerodactyly, and other systemic involvement.
An 83-year-old woman with a history of hypertension and osteoarthritis comes to the office because of abdominal pain with occasional nausea, constipation, muscle weakness, and fatigue over the last 4 months. She denies taking any over-the-counter medications or vitamins. She denies weight changes, change in stool diameter, melena, bright red blood per rectum, or shortness of breath. You notice in her chart that she had a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is normal except for mild kyphosis. Her rectal examination is heme negative. Laboratory studies show: The most appropriate next step is to A. determine parathyroid hormone levels
B. determine serum vitamin D levels
C. determine thyroid stimulating hormone levels
D. order a CT scan of the neck
E. order a serum protein electrophoresis
Explanation: The correct answer is A. This patient has symptomatic hypercalcemia. The most likely etiology in this patient is hyperparathyroidism. This diagnosis is made by checking PTH levels. Since her calcium is elevated, a normal or high PTH level is inappropriate and therefore would help confirm the diagnosis. Vitamin D (choice B) intoxication is typically secondary to patients taking large amounts of vitamin D (often for treatment of hypoparathyroidism). The treatment is to discontinue vitamin supplementation and recheck levels. This patient denied taking over-the-counter medications or vitamins.Ordering a TSH (choice C) is never a bad idea in a patient with a variety of vague complaints since thyroid disease is very common and because it can explain these symptoms. In this patient, you would expect to find hypothyroidism based on her symptoms but an elevated serum calcium is more likely explained by hyperthyroidism secondary to increased bone turnover. Therefore, a PTH level would more likely lead to the correct diagnosis.CT scanning of the neck (choice D) is very sensitive for parathyroid disease but it is not meant to be used as a screening test for hyperparathyroidism. Rather, the diagnosis is made by checking serum calcium and PTH levels.Multiple myeloma is a common disease and can cause hypercalcemia as well. A serum protein electrophoresis (choice E) is helpful in making this diagnosis by demonstrating a monoclonal spike in the beta or gamma globulin region. Our patient lacks anemia, renal disease, or significant back pain which makes multiple myeloma less likely.
A 68-year-old woman is admitted to the hospital because of lethargy and dehydration. She lives alone and has had regular checkups in the office. Her past medical history is significant for diabetes mellitus, which is controlled with diet and oral antidiabetic agents. She has a history of mild systolic hypertension, treated with a thiazide diuretic. Her last visit to your office was 3 months ago, at which time she was started on digoxin for control of heart rate. Since then, she has been taking digoxin and the diuretics without fail with good control of her heart rate and no evidence of heart failure. On admission, she is lethargic, but can be easily aroused. Her skin and mucous membranes are dry. Her temperature is 37.8 C (100.0 F), blood pressure is 110/70 mm Hg, and pulse is 90/min. Examination of the chest, abdomen, and extremities is normal. An electrocardiogram shows atrial fibrillation. Her laboratory studies show: Urine analysis shows red cells, white cells, and few bacteria without any protein. An abdominal radiograph reveals a small, calcified density in the region of the right kidney. The most likely cause for this patient's metabolic abnormality is A. hyperparathyroidism
B. hyperthyroidism
C. metastatic malignancy
D. multiple myeloma
E. thiazide diuretic overdose
Explanation: The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating bone resorption. Serum calcium levels normalize when the patient becomes euthyroid. Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism and should be investigated further.Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and parathyroid hormone levels, normal or elevated urine calcium excretions, and low or normal plasma concentration of phosphates.Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with solid tumors, including lung carcinoma, breast carcinoma, and squamous cell carcinoma of the head and neck. The hypercalcemia is thought to be caused by parathyroid hormone related protein secreted by the tumor. Patients with hematological malignancies may also have increased serum calcium levels, but this is thought to be due to cytokines causing increased osteoclastic activity in the bone.Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine analysis shows protein in urine in multiple myeloma patients.Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum phosphate would likely be depressed. In this patient, although the calcium levels are elevated, the phosphorus levels are high normal.
A 68-year-old woman is admitted to the hospital because of lethargy and dehydration. She lives alone and has had regular checkups in the office. Her past medical history is significant for diabetes mellitus, which is controlled with diet and oral antidiabetic agents. She has a history of mild systolic hypertension, treated with a thiazide diuretic. Her last visit to your office was 3 months ago, at which time she was started on digoxin for control of heart rate. Since then, she has been taking digoxin and the diuretics without fail with good control of her heart rate and no evidence of heart failure. On admission, she is lethargic, but can be easily aroused. Her skin and mucous membranes are dry. Her temperature is 37.8 C (100.0 F), blood pressure is 110/70 mm Hg, and pulse is 90/min. Examination of the chest, abdomen, and extremities is normal. An electrocardiogram shows atrial fibrillation. Her laboratory studies show: Urine analysis shows red cells, white cells, and few bacteria without any protein. An abdominal radiograph reveals a small, calcified density in the region of the right kidney. The most likely cause for this patient's metabolic abnormality is A. hyperparathyroidism
B. hyperthyroidism
C. metastatic malignancy
D. multiple myeloma
E. thiazide diuretic overdose
Explanation: The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating bone resorption. Serum calcium levels normalize when the patient becomes euthyroid. Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism and should be investigated further.Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and parathyroid hormone levels, normal or elevated urine calcium excretions, and low or normal plasma concentration of phosphates.Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with solid tumors, including lung carcinoma, breast carcinoma, and squamous cell carcinoma of the head and neck. The hypercalcemia is thought to be caused by parathyroid hormone related protein secreted by the tumor. Patients with hematological malignancies may also have increased serum calcium levels, but this is thought to be due to cytokines causing increased osteoclastic activity in the bone.Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine analysis shows protein in urine in multiple myeloma patients.Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum phosphate would likely be depressed. In this patient, although the calcium levels are elevated, the phosphorus levels are high normal.
A 70-year-old man with hypertension, hyperlipidemia, and chronic atrial fibrillation is brought to the emergency department for confusion. He was recently diagnosed with multiple myeloma. His medications include furosemide, captopril, atorvostatin, digoxin, and warfarin. He is allergic to penicillin to which he gets a rash. His temperature is 37.0 C (98.6 F), blood pressure is 100/60 mmHg, pulse is 98/min, and respirations are 23/min. Physical examination shows an irregular cardiac rhythm and a soft systolic murmur at his cardiac base. An electrocardiogram shows atrial fibrillation. Laboratory studies show:Sodium 143 mEq/L
Potassium 4.5 mEq/L
Chloride 104 mEq/L
Bicarbonate 26 mEq/L
Calcium 13 mg/dL
Glucose 109 mg/dL
The most appropriate next step is management is to A. administer albumin, intravenously
B. administer a dextrose bolus followed by insulin, intravenously
C. administer magnesium sulfate, intravenously
D. administer pamidronate, intravenously
E. hydrate him with normal saline and then administer furosemide, intravenously
Explanation: The correct answer is E. The most appropriate acute treatment of hypercalcemia is hydration followed by a forced diuresis. It is important to hydrate patients prior to administering the diuretic since most patients with this condition are hypovolemic from hypercalcemia induced nausea/vomiting and diabetes insipitus. Administration of albumin (choice A), albeit a binder of serum calcium, has no role in the management of hypercalcemia. Administration of dextrose followed by insulin (choice B) is one of the treatments of choice for acute hyperkalemia. It has no role in the management of hypercalcemia.Administration of magnesium sulfate (choice C) has no role in the management of hypercalcemia.Administration of pamidronate (choice D), a bisphosphonate which can decrease bone resorption, can be used in the chronic management of hypercalcemia, but has no role in its acute management.
An 18-year-old man with type I diabetes mellitus is brought to the emergency department by a friend after being found comatose. There is a known history of noncompliance with medications, however, there is no known history of drug use. Vital signs are: temperature 37 C (98.6 F), blood pressure 80/65 mm Hg, pulse 110/min, and respirations 17/min. Oxygen saturation obtained while the patient is receiving supplemental oxygen of 2 L/min via nasal cannula is 98%. The patient is comatose and is taking rapid, shallow breaths. Deep tendon reflexes are hypoactive. An intravenous line has been placed in the field. A fingerstick glucose is 430 mg/dL. An arterial blood gas, basic chemistry panel, and toxicology screen has been sent to the laboratory. The next step in the management of this patient is A. a chest x-ray
B. an endotracheal intubation
C. an intravenous fluid replacement with insulin
D. methadone
E. a pulmonary artery catheter insertion
Explanation: The correct answer is C. This patient is suffering from diabetic ketoacidosis (DKA) caused by a severe deficiency of insulin. Clinical symptoms include coma, rapid and shallow breathing, high serum glucose levels, and metabolic acidosis. The immediate management of this patient includes intravenous fluid replacement and insulin infusion. When laboratory results return, electrolyte imbalances must also be corrected.A chest x-ray (choice A) would be complementary to a complete the evaluation of any comatose patient. In this patient with a picture of diabetic ketoacidosis, a chest x-ray would be a secondary concern. The first priority is intravenous fluid replacement and insulin therapy.Endotracheal intubation (choice B) is not necessary at this point as the patient has a normal oxygen saturation. Adequacy of respiration will need to be reassessed when the arterial blood gas results are available. The first priority is intravenous fluid replacement and insulin therapy.Methadone (choice D) is used to treat heroin dependency. A pulmonary artery catheter (choice E) is not yet necessary as the patient is at the present time hemodynamically stable. The first priority is intravenous fluid replacement and insulin therapy.
A 45-year-old man comes to the clinic for a follow-up visit for hypercholesterolemia. On the previous visit, you placed him on a diet to lower his cholesterol. Now he tells you that he was following the diet, although he does not like it. At the same time he expresses concern that because his father died of a heart attack, dietary changes might not be sufficient for him. He hands you an article that he downloaded from the Internet extolling the virtues of a new cholesterol-lowering drug. You promise to look at the article and tell the patient what you think about it during his next visit in 3 months. The article describes a double-blind clinical trial in which patients with cholesterol levels over 240 were assigned to 1 of 3 groups: diet change only, drug only, or diet change and drug combined. Patients were followed over a 6-month period, and changes in cholesterol level from baseline was computed. The results of the study are presented in the table below. The drug was also shown to have significant side effects in 10% of the patients taking the drug. Based on this article, your recommendation to the patient should be A. because there is no difference between the effects of dietary change or taking the drug, the patient can choose which one he prefers
B. diet alone is sufficient and adding the drug will not provide enough clinical advantage to warrant the risk of the side effects
C. studies found on the Internet are not a good source of information for making treatment decisions
D. taking the drug by itself has sufficient clinical merit, so that dietary change is not required
E. taking the drug either with or without dietary change has sufficient clinical effect to merit giving the patient a prescription
F. the drug should be taken, but only in conjunction with dietary change
G. the results of this study may not apply to this patient and a 3-month trial dosage of the drug should be given to see what effect it has
Explanation: The correct answer is B. All three conditions show a lowering of cholesterol levels and the p-values indicate statistically significant differences among all three groups. However, the magnitude of the differences among the groups means that these differences are not clinically significant. Changes of 1 or 2 points in cholesterol levels are unlikely to be clinically meaningful. Because dietary change provides a notable lowering of cholesterol levels and avoids the possible side effects of the drug, this is the therapeutic option that gives the best benefit/risk ratio. Note that, of course, the physician should discuss with the patient his concerns that diet alone is not sufficient and explain the reasoning for this decision in detail.Because there is no difference between the effects of dietary change or taking the drug, the patient can choose which one he prefers (choice A), taking the drug by itself has sufficient clinical merit, so that dietary change is not required (choice D), taking the drug either with or without dietary change has sufficient clinical effect to merit giving the patient a prescription (choice E), and the drug should be taken, but only in conjunction with dietary change (choice F) are all incorrect because the three groups are statistically significant; however, not clinically significant.Studies found on the Internet are not a good source of information for making treatment decisions (choice C) is incorrect, because although everything on the Internet cannot be taken at face value, there are a number of excellent sites that publish valid, important medical information. The fact that the article was from the Internet, by itself, does not invalidate the article as a source of information.The results of this study may not apply to this patient and a 3-month trial dosage of the drug should be given to see what effect it has (choice G) is incorrect, because although the patient may have particularities which make the effects on him different than the published study, the study results should be taken as accurate, unless and until an individual patient's experience proves differently. Otherwise, all research would be useless and every drug would have to be tested on every patient.
A 47-year-old woman comes to the office with newly diagnosed type 2 diabetes mellitus for a follow-up visit regarding laboratory studies that you had ordered. She has no complaints at this time. Her temperature 37 C (98.6 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and weight is 116 kg (255 lb). Visual acuity is 20/20 in both eyes. Her hemoglobin A1C is 6.0% and her fasting blood glucose is 132 mg/dL. During your discussion with her, she relates that her father had diabetes and "went blind." She asks you if she should go to an ophthalmologist. The most appropriate response is: A. "Good visual acuity is an accurate predictor of the absence of diabetic retinopathy."
B. "I will perform yearly funduscopic exams and will refer you for ophthalmology consultation at the first sign of diabetic retinopathy."
C. "Ophthalmology consultation is recommended 5 years after the diagnosis of diabetes and yearly thereafter."
D. "With well-controlled diabetes you will prevent diabetic visual complications making a visit to an ophthalmologist unnecessary at this point."
E. "Yearly ophthalmology appointments should begin now."
Explanation: The correct answer is E. Yearly eye exams by an ophthalmologist are recommended for all patients with type 2 diabetes mellitus beginning at the time of diagnosis. Good visual acuity is not a predictor of the presence or absence of diabetic retinopathy (choice A).Funduscopic exams (choice B) should be a part of a primary care physician's evaluation of a patient with diabetes mellitus; however, the standard of care for diagnosis and treatment of diabetic retinopathy is under the care of an ophthalmologist. Young patients who are newly diagnosed with type 1 diabetes may delay ophthalmology consultation for 5 years in the absence of visual complaints, but this does not apply to type 2 patients (choice C).Good control of diabetes is important in preventing diabetic retinopathy; however, some patients will have diabetic retinopathy despite excellent control (choice D). Furthermore, diabetic patients are more likely to have other ocular diagnoses such as cataracts and glaucoma that are more easily diagnosed and managed by an ophthalmologist.
You are caring for a patient in the intensive care unit who was admitted 2 hours earlier with diabetic ketoacidosis. She is a 19-year-old girl with no known medical problems prior to this admission when her parents brought her in with abdominal pain, nausea, vomiting, and mild confusion. On admission her laboratory results were as follows:Sodium 129 mEq/dL
Potassium 5.5 mEq/dL
Chloride 88 mEq/dL
Bicarbonate 12 mEq/dL
Urea nitrogen, serum 51 mg/dL
Creatinine 2.0 mg/dL
Glucose 697 mg/dL
An insulin drip was started at 11 U/hr and intravenous fluids were started at 250 cc/hr. Two hours later, laboratory studies show:Sodium 132 mEq/dL
Potassium 4.0 mEq/dL
Chloride 89 mEq/dL
Bicarbonate 13 mEq/dL
Urea nitrogen, serum 41 mg/dL
Creatinine 1.9 mg/dL
Glucose 277 mg/dL
Shortly after these laboratory results return, the patient becomes unresponsive. Papilledema is observed bilaterally. The most likely explanation for the patient's rapid deterioration is A. arterial thrombosis associated with diabetic ketoacidosis
B. overlooking of toxic screen in patients initial evaluation
C. rapid lowering of serum glucose
D. use of a relatively hypertonic solution for rehydration
E. worsening lactic acidosis and tissue ischemia
Explanation: The correct answer is C. The target for lowering serum glucose is approximately 50-100 mg/dL/hour. More aggressive lowering of the serum glucose can result in cerebral edema. This is because the CSF glucose decreases more slowly than the serum glucose. If the serum glucose is lowered too rapidly, the CSF fluid is relatively hypertonic compared to the serum. Therefore, water will enter the CSF creating edema. Arterial thrombosis (choice A) occurs with increased frequency in DKA. This can manifest as MI, ischemic limbs, or stoke. The fact that this patient has papilledema suggests that edema is more likely than stroke. This patient's age also makes stroke less likely.Toxic screening for drugs should be part of the initial evaluation of a patient with altered mental status. This patient has an anion gap acidosis with an elevated glucose and likely does have DKA. Therefore, a toxic drug screen (choice B) is not the best answer.Normal saline (choice D) is an appropriate solution for rehydration in this patient. Although the patient's sodium is 129 mEq/dl on admission, when corrected for the elevated glucose, the sodium is 139 mEq/dL. Remember that these patients are very dehydrated on admission and need to be volume resuscitated.Lactic acidosis (choice E) can occur in patients with DKA from prolonged dehydration, infection, or tissue hypoxia. One would suspect that if this patient had a lactic acidosis on admission that it would correct with proper DKA management. You would not expect brain herniation from lactic acidosis.
A 45-year-old woman returns to your office to discuss the results of "blood tests" drawn 3 days earlier when she was complaining of fatigue, weight loss, frequent urination, and blurred vision for the last several weeks. She is a non-smoker and drinks 1 glass of wine per week. She had no past medical or surgical history and a complete physical examination 3 days earlier was unremarkable including a blood pressure of 130/72 mm Hg. Laboratory studies show: Based on these studies, you decide to begin treatment with rosiglitazone. At this time, the most important additional study to perform is A. alanine aminotransferase and aspartate aminotransferase
B. electrocardiogram
C. free thyroxine and T3 reuptake
D. 1-hour glucose tolerance test
E. 24 hour urine protein collection
Explanation: The correct answer is A. This patient has type II (adult-onset) diabetes, which has been diagnosed by a fasting glucose over 200 mg/dl and classic symptoms, including weight loss, blurred vision, and polyuria. The class of drugs known as thiazolidinediones, which includes rosiglitazone (Avandia) and pioglitazone (Actos) are often used as initial monotherapy. The mechanism of action is through enhancing insulin sensitivity of peripheral tissues. However, these medications have been shown to cause liver toxicity. Therefore, it is recommended to check liver enzymes before initiating therapy and every other month for the first year of therapy. EKG (choice B) is not indicated as she has no cardiac complaints, no cardiac history, and is normotensive. Given her complaints of fatigue and weight loss, a thyroid disorder was a possibility in your workup. However, given her normal TSH, further thyroid studies (choice C) are not necessary at this time.1-hour glucose tolerance test(choice D), is no longer used as a method for diagnosing diabetes except as a screening test during pregnancy. The patient's fasting glucose of 206, along with her classic symptoms are enough to make the diagnosis.It is important to screen all diabetic patients for renal disease. Though screening for microalbuminuria is indicated, it is best performed by a spot urine microalbumin/creatinine ratio, instead of a 24 hour urine test(choice E).
A 52-year-old man comes to the clinic because he has been feeling weak and dizzy for the past several days. He also tells you that at the same time he feels somewhat restless and has had a mild headache. His past medical history is significant only for some mild chronic low back pain for which he occasionally takes acetaminophen. His temperature is 37.0 C (98.6 F), blood pressure is 128/78 mm Hg, pulse is 78/min, and respirations are 18/min. Physical examination shows diffuse hyporeflexia and scant basilar crackles in the lungs. Laboratory studies show a leukocyte count of 8,900mm3, hematocrit 40%, platelets 295,000mm3, sodium 126 mEq/L, potassium 3.8 mEq/L, bicarbonate 18 mEq/L, blood urea nitrogen 9 mg/dL, creatinine 0.6 mg/dL, glucose 115 mg/dL, serum osmolality is 258 mOsm/kg (normal 280), and urine osmalality is 150 mmol/L. A chest x-ray shows a 4-centimeter right upper lobe mass and mediastinal adenopathy. The most appropriate next step in management is to A. admit the patient to the hospital and start an infusion of hypertonic (3%) saline until serum sodium normalizes
B. prescribe demeclocycline 150 mg orally 4 times per day, then follow up in 2 weeks with an oncologist
C. refer the patient to cardiothoracic surgery for a lung biopsy
D. restrict the patient to 1500 mL of water per day and obtain CT scan of the chest
E. schedule the patient for the next available oncology appointment
Explanation: The correct answer is D. This patient is presenting with a classic syndrome of inappropriate antidiuretic hormone secretion (SIADH). He has hyponatremia with elevated urine osmolality in the presence of decreased serum osmolality. The clinical symptoms are often vague like his, until more serious seizures or coma present. One of the most common causes of SIADH is small cell cancer of the lung, which he most likely has. The mainstay of treatment is with fluid restriction once the serum sodium level is greater than 125 mEq/L. If the patient's initial sodium is less than 125 mEq/L, then treatment with 0.9% normal saline or possibly even more hypertonic solutions (choice A) may be necessary. It is important not to correct the sodium level too quickly or a deadly syndrome known as central pontine myelinolysis may result. The actual appropriate rate is controversial. However, some recommend a rate of less than 0.5 mmol/L/hr. A CT scan of the chest will also be helpful to both the surgeon and oncologist.Demeclocycline is a medication that actually has nephrogenic diabetes insipidus (the opposite of SIADH) as one of its side effects by blocking the action of antidiuretic hormone. This medication is often adjunctive in the treatment of SIADH. However, you would not simply want to follow up with the patient in 2 weeks (choice B). They need much more vigilant care, as further hyponatremia can result in severe neurologic sequellae.Similarly, a lung biopsy (choice C) and a referral to an oncologist (choice E) will certainly be eventually required in this patient. However, treating the hyponatremia is of prime importance.
A 57-year-old woman comes to your office because she is frustrated about the control of her diabetes. She insists that she has been compliant with her diet but her sugars continue to be poorly controlled. Her current insulin regimen is as follows: 14 units NPH and 6 units regular insulin 30 minutes prior to breakfast, 8 units regular insulin 30 minutes prior to dinner, and 10 units NPH insulin before bedtimeShe has brought along a log of her sugars.DAY Sunday Monday Tuesday Wednesday Thursday Friday Saturday
8a.m.** 230* 188 195 197 210 150 306
11a.m. 133 120 100 179 122 120 111
4p.m. 99 103 129 113 147 133 89
9p.m. 300 198 145 139 306 167 203
*Numbers reflect glucose in mg/dl **8 a.m. sugars are fasting. The most appropriate changes to this patient's insulin regimen would include A. decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH insulin
B. increasing bedtime NPH insulin and increasing dose of pre-dinner regular insulin
C. increasing NPH insulin and regular insulin doses prior to breakfast
D. increasing pre-breakfast regular insulin and increasing pre-dinner regular insulin
E. increasing pre-dinner regular insulin dose only
Explanation: The correct answer is B. This patient has blood sugars which are poorly controlled in the morning and at 9 p.m. Fasting sugars are a reflection of night time NPH doses while late morning sugars are a reflection of a.m. regular doses. Evening sugars reflect dinner time regular insulin. The approximate onset of action, peak effect, and duration of action of NPH insulin and regular insulin are shown below:Type Insulin Duration of action Onset of Action (hr) Peak Effect Peak Effect
Regular 0.5-1 2-4 4-6
NPH 2-4 8-14 16-24
Decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH insulin (choice A) would increase 11 a.m. sugars and decrease 4 p.m. sugars. Increasing NPH insulin and regular insulin doses prior to breakfast (choice C) would be reflected in 11 a.m. and 4 p.m. sugars respectively.Increasing pre-breakfast regular insulin and increasing pre-dinner regular insulin (choice D) would be reflected in 11 a.m. and 9 p.m. sugars respectively.Increasing pre-dinner regular insulin dose only (choice E) would reduce 9 p.m. sugars only.This question might seem confusing, but when confronted with a question that requires that you adjust a patient's insulin regimen it is helpful to answer the question without looking at any answer choices. You could then simply match your answer with the answer choices. Again, remember that a.m. regular insulin will control glucose levels after breakfast. NPH insulin given in the morning will peak around lunch time and will be reflected in post-lunch sugars. Pre-dinner regular insulin will obviously help you with night time or post-dinner sugars and night time NPH will help you control overnight sugars. If you remember this, this question becomes much less overwhelming.
A 60-year-old man with diabetes mellitus, hypertension, hyperlipidemia, and chronic renal insufficiency is admitted to the hospital because of lightheadedness. His medications include NPH insulin, amlodipine, and simvastatin. He is allergic to penicillin to which he gets an angioedema. His temperature is 37.1 C (98.8 F), blood pressure is 98/65 mm Hg, pulse is 87/min, and his respiratory rate is 22/min. On exam, he is ill appearing. His cardiac rhythm is regular and breath sounds are clear bilaterally. His abdominal exam is benign. A chest radiograph shows clear lungs. An electrocardiogram shows a sinus rhythm with peaked T waves. Laboratory studies show a serum sodium of 134 mEq/L, glucose of 98 mg/dL, and potassium of 6.2 mEq/L. The most appropriate intervention at this time is A. administration of glucose, orally
B. administration of insulin and glucose, intravenously
C. administration of furosemide, orally
D. administration of ringers lactate, intravenously
E. administration of sodium chloride, intravenously
Explanation: The correct answer is B. Hyperkalemia with electrocardiographic changes (peaked T waves) requires immediate medical treatment to prevent the onset of hyperkalemia-induced dysrhythmias. Administration of insulin intravenously causes serum potassium to move intracellularly, acutely reducing serum potassium. Glucose is co-administered to prevent insulin-induced hypoglycemia.Oral glucose (choice A) is of no utility in the treatment of hyperglycemia. Even when insulin is used for the treatment of hyperkalemia, glucose should be co-administered intravenously.Oral furosemide (choice C) is an appropriate choice for the long-term treatment of hyperkalemia, i.e., once the acute hyperkalemia has been treated. Interventions such as insulin and glucose simply cause the potassium to shift intracellularly. Its excretion can then be promoted by administration of diuretic agents such as furosemide.Ringers lactate (choice D) should be avoided with hyperkalemic patients since it contains potassium as a constituent (4 mEq/L).Sodium chloride (choice E) is not useful in the management of hyperkalemia.
A 61-year-old woman with chronic renal insufficiency due to long-standing diabetes mellitus comes to the office with a fever, cough, shaking chills, and fatigue. She has long-standing diabetes mellitus with her last hemoglobin A1C being 9.1%, BUN 51 mg/dL, and creatinine 2.1 mg/dL. A chest radiograph demonstrates a right lower lobe infiltrate. Oral antibiotics are prescribed for the patient. The most correct statement concerning a diabetic patient with an infectious process is: A. Antimicrobial dosing must be adjusted due to decreased liver function
B. Antimicrobial dosing must be adjusted due to decreased renal function
C. Diabetics have the same epidemiology of pulmonary infections as non-diabetics
D. It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics
E. Oral antibiotics are not efficacious for treating pneumonia in diabetics
Explanation: The correct answer is B. All drugs (substances in general) are eliminated from the body by means of either renal or hepatic clearance or both. This is one of the most important concepts known by physicians. Almost every patient that presents to inpatient medical services today has some impairment of one or both of these mechanisms. This must be kept in mind when prescribing any drug. In the case of this patient, renal antibiotic dosing schedules for variable renal function are available to every student and house officer and should be consulted regularly. This patient has a creatinine of 2.1 mg/dL, reflecting abnormal renal function. Antimicrobial dosing must be adjusted due to decreased liver function (choice A), although true as a general rule, is not particularly relevant to diabetics since their disease has no impact on liver function. We have no specific evidence that this patient has impaired hepatic function. Diabetics have the same epidemiology of pulmonary infections as non-diabetics (choice C) is incorrect as diabetics are more likely to suffer from Staphylococcus aureus and fungal pneumonia.It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics (choice D) is incorrect. Although certain patient populations tend to have anatomical variation in the location of their pneumonia, the common relationship between all of them is that they suffer from some sort of aspiration. Examples include intubated patients on mechanical ventilation and alcoholics. Diabetics are not included in this group. Oral antibiotics are not efficacious for treating pneumonia in diabetics (choice E) is false. Oral antibiotic efficacy is determined by the causative organism and location of the infection. Some specific dysfunctions such as gastric achlorhydria or bowel obstruction may interfere with oral efficacy, but not simply the presence of diabetes. Being a diabetic may make one prone to more malignant infections. There is no data that initial treatment of community acquired pneumonia in diabetics should be any different when compared to non-diabetics.
A 65-year-old woman comes to the clinic for a follow up visit after being diagnosed with type II diabetes mellitus. She is obese with a history of hypertension, hyperlipidemia, and osteoarthritis. Despite a 3-month trial of diet and exercise, her weight has increased by 3 pounds. In addition, her hemoglobin A1C has increased from 7.8% to 9.0% and her fasting blood sugar ranged from 167-188 mg/dL on the glucometer she now uses at home. With the exception of an elevated glucose, her laboratory results are within normal limits. The most appropriate pharmacotherapy for this patient is A. Acarbose
B. Chlorpropamide
C. insulin NPH at bedtime
D. insulin 70/30 BID
E. metformin
Explanation: The correct answer is E. Metformin acts predominately to decrease hepatic glucose production in the liver. It is an excellent choice for obese patients with diabetes because it promotes modest weight loss by actually decreasing the amount of insulin necessary because of decreased glucose produced by the liver. It is an appropriate drug for monotherapy or combination therapy of diabetes. It should not be used in patients with renal failure or those patients who are 80 years of older (creatinine clearance decreases with age) because or the risk of lactic acidosis. When metformin is used correctly, complications are uncommon. Because the amount of insulin secreted is not increased, it does not cause hypoglycemia.Acarbose (choice A) is an alphaglucosidase inhibitor. It works by decreasing the rate of glucose entry into the blood stream, thereby preventing some of the post prandial hyperglycemia. Acarbose has been shown to give a slight decrease in hemoglobin A1C concentrations. In clinical practice, these drugs are poorly tolerated because of gastrointestinal side effects such as diarrhea, bloating, and gas. Chlorpropamide (choice B) is a first-generation sulfonylurea. It works (as do all drugs in the sulfonylurea class) by binding to a receptor on the beta cells of the pancreas and stimulating insulin secretion. This class of drugs can be used as first-line treatment or can be used in combination with other medications. Chlorpropamide is rarely used today because of its propensity to cause more hypoglycemia than newer drugs in the class.Patients on multiple medications who continue to have poor glycemic control can be tried on a bedtime dose of NPH insulin. (choice C). If this is not effective, then twice a day injections with 70/30 should be added.Insulin 70/30 (choice D) is typically used only if poor control is achieved with oral agents. Obviously, most patients would prefer to take medication by mouth rather than injecting themselves with insulin. An exception to this would be a type II diabetic who presents with symptoms of hyperglycemia such as weight loss, polyuria or polydipsia. These patients can be started on insulin as initial therapy. Above imformation from Clinical Geriatrics "Improving Disease Management with New Treatments for Type 2 Diabetes Mellitus" Volume 8, number 7, June 2000.
A 63-year-old man comes to the office because of "problems seeing." He says that his wife is making him "get some help" because he got into a minor car accident last night, and it was his fault because he had difficulty seeing. His vision is "fine" during the day, but he is basically "blind as a bat" when it is dark. He admits to an "occasional bottle of vodka." He has dry skin with multiple, diffuse areas of hyperkeratosis. His condition would most likely have been prevented by supplementation with A. niacin
B. vitamin A
C. vitamin B1
D. vitamin B12
E. vitamin C
Explanation: The correct answer is B. This patient most likely has a vitamin A (retinoic acid) deficiency, which is characterized by night blindness and dry, hyperkeratotic skin. It can progress to conjunctival dryness, corneal ulceration, and necrosis. It occurs in patients with malabsorption or proteinuria, liver disease, alcoholics, and those receiving total parenteral nutrition (TPN).Niacin (choice A) deficiency, which is often called pellagra, is characterized by diarrhea, dementia, and dermatitis. It occurs in individuals with a high intake of maize (corn). It is not associated with night blindness.Vitamin B1 (thiamine) deficiency (choice C), which is often called beri-beri, is characterized by high output heart failure and central nervous system disturbances (Wernicke-Korsakoff syndrome). Wernicke-Korsakoff syndrome occurs in alcoholics and is associated with nystagmus, ataxia, confabulation, and retrograde amnesia. It is not associated with night blindness.A deficiency of vitamin B12 (choice D) is associated with megaloblastic anemia and peripheral neuropathy. It is not associated with night blindness. It occurs in individuals with pernicious anemia, postgastrectomy, and those with intestinal organisms or ileal abnormalities. A deficiency of vitamin C (choice E), which is often called scurvy, is characterized by easy bruising, perifollicular hemorrhages, purpura, poor wound healing, bone lesions, and emotional changes. It is not commonly associated with night blindness. It occurs in individuals with diets devoid of citrus fruits and vegetables.
An 11-year-old girl with insulin-dependent diabetes mellitus is brought to the emergency department by a friend's father because of severe abdominal pain and vomiting for the past 12 hours. The friend's father says that she has been complaining of mild stomach "cramps" and "thirst" for the past few days, but nothing this extreme. When he leaves the room, she reluctantly admits that she has not been taking her insulin because she is mad at her parents for going away to Europe and "leaving her" for 5 days. Her blood pressure is 100/70 mm Hg, pulse is 98/min, and respirations are 30/min. Physical examination shows dry skin and mucus membranes and diffuse abdominal pain. Laboratory studies show:Serum
Glucose 550 mg/dL
Sodium 138 mEq/L
Potassium 5.8 mEq/L
Chloride 94 mEq/L
Bicarbonate 10 mEq/L
Intravenous isotonic saline and insulin are given and she is admitted to the pediatric intensive care unit for careful monitoring and management. Two hours later, potassium is added, as her glucose and potassium levels begin to drop rapidly. All seems to be going well until half an hour later when the nurse runs over to you frantically saying that the patient suddenly complained of a headache, began to vomit, and became "completely disoriented." You rush to the bedside to find her obtunded. The most appropriate immediate management is to A. add more potassium to the intravenous solution
B. add phosphate to the intravenous solution
C. add sodium bicarbonate to the intravenous solution
D. administer a bolus infusion of mannitol
E. increase the dose of insulin
Explanation: The correct answer is D. This patient has diabetic ketoacidosis (DKA) and has most likely developed cerebral edema, which should be treated with mannitol and dexamethasone. If this is not effective, hyperventilation should be induced. DKA is characterized by hyperglycemia, osmotic diuresis, metabolic acidosis, and elevated ketones. The typical clinical presentation is abdominal pain, nausea, vomiting, polyuria, and lethargy. It is usually precipitated by an infection, stress, a cessation of insulin intake, or surgery. The initial treatment includes insulin and isotonic saline or Ringer's lactate. As glucose and potassium levels begin to fall, potassium and glucose solutions must be given. Bicarbonate is given to patients with severe acidosis. If the glucose level is corrected too rapidly and glucose is not added to the intravenous fluids as the levels fall below 300 mg/dL, cerebral edema may develop. Clinically, cerebral edema manifests as acute altered mental status, vomiting, and a headache. A CT scan is used to make the diagnosis. Adding more potassium to the intravenous solution (choice A) would not be the appropriate management of cerebral edema, which requires mannitol. This patient's acute complication is inconsistent with hypokalemia, which is typically associated with cardiac arrhythmias.Adding phosphate to the intravenous solution (choice B) is an important part of the treatment of DKA. However, this patient is most likely suffering from cerebral edema, which is a life-threatening condition that requires rapid treatment with mannitol, not phosphate. Patients with hypophosphatemia typically complain of muscle weakness.Sodium bicarbonate (choice C) is typically used in severely acidotic patients with hypotension. It is not used to treat cerebral edema.Increasing the dose of insulin (choice E) is incorrect because this patient has cerebral edema, which is most likely caused by the rapid fall of glucose, and so you would not want the glucose levels lowered even more rapidly.
A 23-year-old man is admitted to the medical services for dehydration. He had just completed a marathon that afternoon and was brought to the hospital by his sister who found him to be lethargic and confused. His sister informs you that he has been training very vigorously for the marathon and completed the marathon in near-record time by not stopping for rehydration at all of the available rest stops. On examination, the patient is a well-developed man. He is speaking using unclear words and is warm to the touch with stable vital signs. His skin is very dry and his lips are chafed. His serum sodium is 163 mEq/L. The result is confirmed with the laboratory. The most appropriate management at this time is A. intravenous half normal saline repletion
B. intravenous lactated ringers repletion
C. intravenous normal saline repletion
D. oral free water repletion
E. oral thiazide diuretics
Explanation: The correct answer is D. This patient has hypernatremia as a consequence of insensible free water losses. He needs free water repletion with one half the free water deficit being given in the first 12 hours and the remaining half over the next 24 hours. The serum sodium should fall by no more than 0.5mEq/L/hour (12 mEq/day). Intravenous half-normal saline repletion (choice A) will worsen the condition. Although there is more free water in this preparation, the added sodium will likely worsen this patient's condition. There is no role for intravenous lactated ringers repletion (choice B) in correcting hypernatremia since it has a similar sodium content as normal saline. Intravenous normal saline repletion (choice C) will aggravate the condition by providing only some free water and the remainder sodium. This is used to replete some forms of hyponatremia.Oral thiazide diuretics (choice E) are often a treatment for hypernatremia when salt sodium excess is the primary problem. This can occur with hypertonic dialysis solutions.
A 32-year-old woman comes to the office because of palpitations and anxiety for a few months. She further complains that, "My right eye is bulging out of my head and I see double." Examination reveals visual acuity of 20/20 in both eyes, exophthalmos of the right eye, and redness in both eyes, worse in the left eye. You order a sensitive thyroid stimulating hormone test, which comes back at 0.1 U/mL. At this time the most correct statement about this patient's condition is: A. Cigarette smoking has been shown to increase the severity of exophthalmos in this disease
B. Diplopia observed in this condition is from
B. mammography
C. a MRI of the brain
D. a MRI of the lumbar spine
E. sildenafil citrate
Explanation: The correct answer is C. This patient has impotence, loss of libido, and galactorrhea related to hyperprolactinemia. The most common cause of this in men is probably medication induced, however, he is on no medications. The next main thing to rule out is a prolactin secreting microadenoma by an MRI of the brain.Bromocriptine (choice A) may end up being the treatment of choice for this patient if a microadenoma is found. However the diagnosis should be made prior to treatment. If bromocriptine therapy fails to relieve symptoms, or if the adenoma grows/begins causing other symptoms, referral to neurosurgery to evaluate for transphenoidal resection would be warranted.There is no indication for a mammogram (choice B) or an MRI of the lumbar spine (choice D) in this case.Sildenafil (choice E) also may end up being helpful in this case for the patient's symptoms. However, again making the underlying diagnosis is the most appropriate first step in the work up.
A 23-year-old woman comes to the clinic for a pre-employment examination. She recently moved to the area from out of state and got a job at a local small business. Her past medical history is significant only for diabetes mellitus type I, which she has had since age 13. Her only medication is insulin, which is infused via an insulin pump. She denies smoking or using illicit drugs. She admits to social alcohol consumption less than once a week and says she runs 2 miles daily. She is not sexually active. You perform a full physical examination. Her temperature is 37.1 (98.8 F), blood pressure is 136/89 mm Hg, pulse is 54/min, and respirations are 12/min. Her skin is warm and dry. Cardiovascular examination reveals a normal S1, S2 with no murmurs appreciated. Respirations are equal bilaterally without any abnormal breath sounds. Extremities show no clubbing, cyanosis, or edema. Strength is equal bilaterally and sensation is full throughout. The patient exhibits normal reflexes. She returns to the clinic several more times and her blood pressure remains elevated. The most appropriate initial pharmacotherapy for this patient is A. amlodipine
B. atenolol
C. enalapril
D. furosemide
E. hydrochlorothiazide
Explanation: The correct answer is C. This patient is a type I diabetic with mild hypertension. The Joint National Committee recommends ACE inhibitors, such as enalapril, as first-line treatment of hypertension in diabetics. Multiple studies have proven that ACE inhibitors prevent microalbuminuria and thus preserve renal function. Amlodipine (choice A) is a calcium channel blocker commonly prescribed for hypertension. However, it has not been proven to have the renal protective properties of ACE inhibitors. Therefore, choosing amlodipine is incorrect.Atenolol (choice B) is a beta-blocker that is often used as a first-line agent in non-diabetics. However, beta-blockers should be avoided in patients with type I diabetes, asthma, and depression. Additionally, the patient's low heart rate would contraindicate the use of a beta-blocker.Furosemide (choice D) and hydrochlorothiazide (choice E), a thiazide diuretic and a loop diuretic, are often used as initial agents in the treatment of hypertension due to their efficacy and cost effectiveness. However, the renal protective benefits of an ACE inhibitor make enalapril a more appropriate choice for this patient.
A 37-year-old accountant is hospitalized for a laparoscopic cholecystectomy. The day after his surgery, he reports feeling palpitations in his chest. He says that even prior to his hospitalization he had been feeling nervous and has noticed himself perspiring more easily. His past medical history is significant for a resection of a benign brain tumor during childhood. He also mentions that he may have lost weight, although he has not been dieting. Physical examination reveals a thin, anxious appearing male. His lungs are clear and cardiac auscultation demonstrates an irregularly irregular rhythm and no murmurs. Neurologic examination is significant for a fine tremor in both hands. An electrocardiogram performed at the bedside shows atrial fibrillation. The most appropriate study at this time to evaluate this patient's symptoms is A. a chest x-ray
B. a CT scan of the head
C. an exercise tolerance test
D. a serum thyroid stimulating hormone
E. a ventilation/perfusion scan
Explanation: The correct answer is D. Nervousness, tremor, heat intolerance, and weight loss are classic signs and symptoms of hyperthyroidism. Hyperthyroidism is a well known cause of atrial fibrillation. This arrhythmia will respond to the treatment of the underlying endocrine abnormality. A serum thyroid stimulating hormone (TSH) level will be abnormally low in patients with hyperthyroidism and is a very specific test for this disorder.A chest x-ray (choice A) is not a useful study in the evaluation of atrial fibrillation in the setting of hyperthyroidism. There is no reason to suspect other primary lung diseases in an otherwise healthy young male to warrant a chest x-ray.A CT of the head (choice B) will not provide information about the etiology of the patient's atrial fibrillation. He has a distant history of surgical resection of a benign brain tumor and there is no reason to suspect metastatic disease. There is no association between primary brain pathology and atrial fibrillation.An exercise tolerance test (choice C) is an examination to evaluate for cardiac ischemia or past infarct. This study is performed by having a patient exercise on a treadmill while wearing the electrocardiogram leads. A continuous EKG is performed during exercise to monitor for signs of ischemia. Cardiac ischemia is a very common cause of atrial fibrillation. However, there is no reason to suspect an ischemic etiology of this arrhythmia in a young, otherwise healthy patient.A ventilation/perfusion scan (choice E) is a good diagnostic study for the evaluation of a pulmonary embolism. A pulmonary embolism is a known cause of atrial fibrillation. Although recent surgery and hospitalization does put the patient at increased risk for thromboembolic disease, he does not have shortness of breath, chest pain, or other classic symptoms of a pulmonary embolism. Young and healthy patients do develop thromboembolic disease in the setting of pelvic and lower extremity trauma, and prolonged hospitalization or bedrest.
A 20-year-old college student is brought to the emergency department by his girlfriend because of the sudden onset of a headache, shaking, sweating, and blurry vision. She says that he became very confused during the taxicab ride over to the hospital, asking, "where are you taking me to, the airport?" He was fully aware that they were going to the hospital as they left their apartment 5 minutes earlier. These symptoms started as they were lying in bed going to sleep, 3 hours after coming back from the local Italian restaurant, where they both ate fettucine alfredo. They did not drink any alcohol tonight. He has had similar, but milder, symptoms on four previous occasions in the past few years. He has no other medical conditions and does not take any medications. His temperature is 37.0 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 22/min. He is not oriented to person, place, or time. He begins to lose consciousness during the physical examination, which is otherwise unremarkable. At this time the most appropriate conclusion is: A. He should drink a glass of orange juice immediately
B. An intravenous bolus of glucose as a 50 % solution should be given immediately
C. An intravenous bolus of isotonic saline should be given immediately
D. Naloxone, given intravenously every 2 minutes, will reverse this patient's symptoms
E. Physostigmine, given intravenously over 2 minutes, will reverse this patient's symptoms
Explanation: The correct answer is B. This patient is most likely experiencing the symptoms of hypoglycemia, which should be treated with intravenous glucose until the patient can eat a meal. There are two categories of symptoms associated with hypoglycemia: the autonomic response and the neuroglycopenic response. The former is due to excessive secretion of epinephrine/norepinephrine and consists of tremor, palpitations, sweating, hunger, and anxiety. The latter is caused by central nervous system dysfunction and includes dizziness, headache, blurry vision, confusion, abnormal behavior, and a loss of consciousness. Symptoms do not usually occur until the blood glucose falls below 45 mg/dL. Causes of hypoglycemia include postprandial hypoglycemia, fasting hypoglycemia, insulinomas, and factitious hypoglycemia. This patient should not have a glass of orange juice (choice A) right now because he is losing consciousness and therefore cannot eat or drink. The initial treatment for hypoglycemia with both autonomic and neuroglycopenic symptoms is intravenous glucose. This can be discontinued when the patient is able to eat and drink.Administration of isotonic saline, intravenously (choice C) is part of the initial treatment for diabetic ketoacidosis. 5% glucose solutions should be added when the plasma glucose level falls below 300 mg/dL. This would be inappropriate for a hypoglycemic because they need glucose. The symptoms of DKA include increased urination, thirst, abdominal pain, mental status changes, anorexia, nausea, and vomiting. The patient in this case does not have these symptoms.Naloxone would reverse this patient's symptoms (choice D) if they were caused by an opioid overdose, not hypoglycemia. Naloxone is an opioid antagonist that competes for the opioid receptors and will block the effects of heroin and other opioids. Symptoms of an opioid overdose include miosis, respiratory depression, coma, hypotension, and bradycardia. The patient in this case does not have these symptoms.Physostigmine would reverse this patient's symptoms (choice E) if they were caused by anticholinergic poisoning, not hypoglycemia. The symptoms of anticholinergic poisoning can occur with overdoses of antihistamines, atropine, tricyclic antidepressants, and scopolamine, and include hyperthermia, vasodilatation, decreased salivation, mydriasis, delirium, and hallucinations. The girlfriend did not say that he took any medications. The fact that these symptoms occurred a few hours after a meal and that he has had similar episodes in the past and his physical examination did not reveal mydriasis or hyperthermia makes his condition more consistent with hypoglycemia than anticholinergic poisoning.
A 29-year-old woman comes to the office because of a 12-pound weight gain in the past 3 months. She does not seem to think that it is related to a change in appetite. She has no chronic medical conditions and takes no medications. She exercises regularly and drinks a glass of wine with dinner each night. She says that she usually only eats foods that are labeled "low-fat" or "fat free." She has recently moved to your town to live with her fiancee and just started working as a kindergarten teacher. She enjoys her job and is very happy in her new home and with her fiancee. She is 168 cm (5 ft 6 in) tall and weighs 67 kg (148 lb). Her blood pressure is 135/90 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination is unremarkable. She is picking her cuticles and tapping her feet during the history and examination. The most appropriate next step is to A. ask her if she recently quit smoking
B. determine thyroid stimulating hormone levels
C. order a biochemical profile
D. order a dexamethasone suppression test
E. refer her to a nutritionist
Explanation: The correct answer is A. In the evaluation of weight gain, the first step is to perform a thorough history and physical examination. If the patient tells you that they have not really had a change in appetite and have had a recent weight gain, you need to ask about medications, such as tricyclics, steroids, and antipsychotics and about smoking cessation and psychiatric disorders. This patient appears fidgety, which may be consistent with smoking cessation. Smoking cessation is often associated with a small weight gain (5-10 lbs), but it can lead to more dramatic weight gain in others. Before you perform any expensive and unnecessary diagnostic studies, you should first perform a detailed history.Determining thyroid stimulating hormone levels (choice B) is appropriate in the evaluation of weight gain if there is a negative drug history, no recent smoking cessation, and a normal biochemical profile. Since hypothyroidism is part of the differential diagnosis for weight gain, you should consider it early in the work-up, but a biochemical profile should be performed first.The initial work-up for weight gain is a detailed history, including medication and drug use and recent smoking cessation. If those are negative, then a biochemical profile (choice C) is indicated. A biochemical profile may indicate the presence of diabetes mellitus or Cushing syndrome. Diabetes will most likely lead to an elevated glucose, while Cushings is sometimes associated with hypokalemia, hypochloremia, metabolic alkalosis, hyperglycemia, and hypercholesterolemia.A dexamethasone suppression test (choice D) is part of the initial evaluation of Cushing syndrome. You should first perform a complete history and if negative for such things as drug history, recent smoking cessation, and a psychiatric disorder, you should then order a biochemical profile. A dexamethasone suppression test should be ordered if the biochemical profile is suspicious for Cushing syndrome (hypokalemia, hypochloremia, metabolic alkalosis, hypercholesterolemia, and hyperglycemia).Referring her to a nutritionist (choice E) is inappropriate at this time. The case says that the patient has had weight gain with no change in appetite or eating habits. She requires a thorough history and examination, and if negative, an evaluation for a medical condition such as Cushing syndrome, diabetes mellitus, thyroid disease (even though this is usually associated with a poor appetite), and fluid overload. A nutritionist may be valuable later if the complete evaluation is negative and you determine that she has poor eating habits. Obviously in that case you should try to help her with her dietary habits, but if you are unsuccessful, a nutritionist may be helpful.
A 44-year-old obese woman comes to the clinic for a routine follow up visit for diabetes. Her diabetes has been poorly controlled in the past year and her hemoglobin A1c level was last at 11%. She denies any new problems with her health. On physical examination, you note firm, non-pitting induration on her upper back with a clear cut-off border. Within the indurated areas there are small papules resembling follicular prominences. Under her breasts are beefy-red patches in the moist areas with satellite lesions. On her left pretibial area, there is a dusky-red elevated plaque with a sharply circumscribed border. There is an orange-hue to this lesion, and the center of the lesion is flattened and atrophic. In the order of these descriptions, the cutaneous manifestations of diabetes that this patient has are A. scleredema, candidiasis, necrobiosis lipoidal diabeticorum
B. scleredema, candidiasis, stasis dermatitis
C. scleredema, tinea corporis, stasis dermatitis
D. scleroderma, candidiasis, necrobiosis lipoidal diabeticorum
E. scleroderma, tinea corporis, stasis dermatitis
Explanation: The correct answer is A. Scleredema, candidiasis, necrobiosis lipoidal diabeticorum (NLD) is correct, because these three are all commonly associated with diabetes. Scleredema is a connective disorder with sudden onset of marked, nonpitting, symmetric induration of the posterior and lateral aspects of the neck spreading to shoulders, upper back, and proximal arms. The indurations are of wood-like consistency. Erythematous papular eruption occurs during the early stage of the disease. A syndrome has been recognized consisting of scleredema of long duration, obesity, maturity onset, latent or overt diabetes, and high incidence of cardiovascular disease. Candida albicans flourishes in the recesses created by redundant skin folds. Exacerbating factors may include diabetes mellitus, systemic medications, nutritional factors, and diminished salivary function. NLD is relatively asymptomatic, and is characteristically found on the anterior and lateral lower legs. They may also be present on the face, arms, and trunk. They begin as small, red nodules that enlarge to a plaque with irregular, flattened and eventually depressed atrophy. NLD seems to be a marker for diabetes.Stasis dermatitis (choice B) is incorrect because classical stasis dermatitis appears on the medial surface of lower extremities with hyperpigmented patches mixed with occasional erythematous plaques. Often times, one can appreciate tortuous enlarged varicose veins.Tinea corporis (choice C) is incorrect because it generally presents with erythematous annular plaques, with central clearing and no satellite lesions.Scleroderma (choice D) and (choice E) is incorrect, because this is a connective disorder associated with the tightening of the skin, difficulty swallowing, telangiectasia, calcinosis, sclerodactyly, and other systemic involvement.
An 83-year-old woman with a history of hypertension and osteoarthritis comes to the office because of abdominal pain with occasional nausea, constipation, muscle weakness, and fatigue over the last 4 months. She denies taking any over-the-counter medications or vitamins. She denies weight changes, change in stool diameter, melena, bright red blood per rectum, or shortness of breath. You notice in her chart that she had a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is normal except for mild kyphosis. Her rectal examination is heme negative. Laboratory studies show: The most appropriate next step is to A. determine parathyroid hormone levels
B. determine serum vitamin D levels
C. determine thyroid stimulating hormone levels
D. order a CT scan of the neck
E. order a serum protein electrophoresis
Explanation: The correct answer is A. This patient has symptomatic hypercalcemia. The most likely etiology in this patient is hyperparathyroidism. This diagnosis is made by checking PTH levels. Since her calcium is elevated, a normal or high PTH level is inappropriate and therefore would help confirm the diagnosis. Vitamin D (choice B) intoxication is typically secondary to patients taking large amounts of vitamin D (often for treatment of hypoparathyroidism). The treatment is to discontinue vitamin supplementation and recheck levels. This patient denied taking over-the-counter medications or vitamins.Ordering a TSH (choice C) is never a bad idea in a patient with a variety of vague complaints since thyroid disease is very common and because it can explain these symptoms. In this patient, you would expect to find hypothyroidism based on her symptoms but an elevated serum calcium is more likely explained by hyperthyroidism secondary to increased bone turnover. Therefore, a PTH level would more likely lead to the correct diagnosis.CT scanning of the neck (choice D) is very sensitive for parathyroid disease but it is not meant to be used as a screening test for hyperparathyroidism. Rather, the diagnosis is made by checking serum calcium and PTH levels.Multiple myeloma is a common disease and can cause hypercalcemia as well. A serum protein electrophoresis (choice E) is helpful in making this diagnosis by demonstrating a monoclonal spike in the beta or gamma globulin region. Our patient lacks anemia, renal disease, or significant back pain which makes multiple myeloma less likely.
A 68-year-old woman is admitted to the hospital because of lethargy and dehydration. She lives alone and has had regular checkups in the office. Her past medical history is significant for diabetes mellitus, which is controlled with diet and oral antidiabetic agents. She has a history of mild systolic hypertension, treated with a thiazide diuretic. Her last visit to your office was 3 months ago, at which time she was started on digoxin for control of heart rate. Since then, she has been taking digoxin and the diuretics without fail with good control of her heart rate and no evidence of heart failure. On admission, she is lethargic, but can be easily aroused. Her skin and mucous membranes are dry. Her temperature is 37.8 C (100.0 F), blood pressure is 110/70 mm Hg, and pulse is 90/min. Examination of the chest, abdomen, and extremities is normal. An electrocardiogram shows atrial fibrillation. Her laboratory studies show: Urine analysis shows red cells, white cells, and few bacteria without any protein. An abdominal radiograph reveals a small, calcified density in the region of the right kidney. The most likely cause for this patient's metabolic abnormality is A. hyperparathyroidism
B. hyperthyroidism
C. metastatic malignancy
D. multiple myeloma
E. thiazide diuretic overdose
Explanation: The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating bone resorption. Serum calcium levels normalize when the patient becomes euthyroid. Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism and should be investigated further.Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and parathyroid hormone levels, normal or elevated urine calcium excretions, and low or normal plasma concentration of phosphates.Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with solid tumors, including lung carcinoma, breast carcinoma, and squamous cell carcinoma of the head and neck. The hypercalcemia is thought to be caused by parathyroid hormone related protein secreted by the tumor. Patients with hematological malignancies may also have increased serum calcium levels, but this is thought to be due to cytokines causing increased osteoclastic activity in the bone.Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine analysis shows protein in urine in multiple myeloma patients.Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum phosphate would likely be depressed. In this patient, although the calcium levels are elevated, the phosphorus levels are high normal.
A 68-year-old woman is admitted to the hospital because of lethargy and dehydration. She lives alone and has had regular checkups in the office. Her past medical history is significant for diabetes mellitus, which is controlled with diet and oral antidiabetic agents. She has a history of mild systolic hypertension, treated with a thiazide diuretic. Her last visit to your office was 3 months ago, at which time she was started on digoxin for control of heart rate. Since then, she has been taking digoxin and the diuretics without fail with good control of her heart rate and no evidence of heart failure. On admission, she is lethargic, but can be easily aroused. Her skin and mucous membranes are dry. Her temperature is 37.8 C (100.0 F), blood pressure is 110/70 mm Hg, and pulse is 90/min. Examination of the chest, abdomen, and extremities is normal. An electrocardiogram shows atrial fibrillation. Her laboratory studies show: Urine analysis shows red cells, white cells, and few bacteria without any protein. An abdominal radiograph reveals a small, calcified density in the region of the right kidney. The most likely cause for this patient's metabolic abnormality is A. hyperparathyroidism
B. hyperthyroidism
C. metastatic malignancy
D. multiple myeloma
E. thiazide diuretic overdose
Explanation: The correct answer is B. Hyperthyroidism may cause increased calcium by stimulating bone resorption. Serum calcium levels normalize when the patient becomes euthyroid. Patients with hyperthyroidism do have cardiac effects from increased levels of thyroid hormone. Recent onset of atrial fibrillation, without cardiac cause, should raise suspicion for hyperthyroidism and should be investigated further.Patients with hyperparathyroidism (choice A) typically have elevated serum calcium and parathyroid hormone levels, normal or elevated urine calcium excretions, and low or normal plasma concentration of phosphates.Hypercalcemia of malignancy (choice C) is usually very high and seen in patients with solid tumors, including lung carcinoma, breast carcinoma, and squamous cell carcinoma of the head and neck. The hypercalcemia is thought to be caused by parathyroid hormone related protein secreted by the tumor. Patients with hematological malignancies may also have increased serum calcium levels, but this is thought to be due to cytokines causing increased osteoclastic activity in the bone.Multiple myeloma (choice D) causes hypercalcemia by increased cellular lysis. Urine analysis shows protein in urine in multiple myeloma patients.Thiazide diuretic overdose, (choice E) may increase serum calcium levels, but serum phosphate would likely be depressed. In this patient, although the calcium levels are elevated, the phosphorus levels are high normal.
A 70-year-old man with hypertension, hyperlipidemia, and chronic atrial fibrillation is brought to the emergency department for confusion. He was recently diagnosed with multiple myeloma. His medications include furosemide, captopril, atorvostatin, digoxin, and warfarin. He is allergic to penicillin to which he gets a rash. His temperature is 37.0 C (98.6 F), blood pressure is 100/60 mmHg, pulse is 98/min, and respirations are 23/min. Physical examination shows an irregular cardiac rhythm and a soft systolic murmur at his cardiac base. An electrocardiogram shows atrial fibrillation. Laboratory studies show:Sodium 143 mEq/L
Potassium 4.5 mEq/L
Chloride 104 mEq/L
Bicarbonate 26 mEq/L
Calcium 13 mg/dL
Glucose 109 mg/dL
The most appropriate next step is management is to A. administer albumin, intravenously
B. administer a dextrose bolus followed by insulin, intravenously
C. administer magnesium sulfate, intravenously
D. administer pamidronate, intravenously
E. hydrate him with normal saline and then administer furosemide, intravenously
Explanation: The correct answer is E. The most appropriate acute treatment of hypercalcemia is hydration followed by a forced diuresis. It is important to hydrate patients prior to administering the diuretic since most patients with this condition are hypovolemic from hypercalcemia induced nausea/vomiting and diabetes insipitus. Administration of albumin (choice A), albeit a binder of serum calcium, has no role in the management of hypercalcemia. Administration of dextrose followed by insulin (choice B) is one of the treatments of choice for acute hyperkalemia. It has no role in the management of hypercalcemia.Administration of magnesium sulfate (choice C) has no role in the management of hypercalcemia.Administration of pamidronate (choice D), a bisphosphonate which can decrease bone resorption, can be used in the chronic management of hypercalcemia, but has no role in its acute management.
An 18-year-old man with type I diabetes mellitus is brought to the emergency department by a friend after being found comatose. There is a known history of noncompliance with medications, however, there is no known history of drug use. Vital signs are: temperature 37 C (98.6 F), blood pressure 80/65 mm Hg, pulse 110/min, and respirations 17/min. Oxygen saturation obtained while the patient is receiving supplemental oxygen of 2 L/min via nasal cannula is 98%. The patient is comatose and is taking rapid, shallow breaths. Deep tendon reflexes are hypoactive. An intravenous line has been placed in the field. A fingerstick glucose is 430 mg/dL. An arterial blood gas, basic chemistry panel, and toxicology screen has been sent to the laboratory. The next step in the management of this patient is A. a chest x-ray
B. an endotracheal intubation
C. an intravenous fluid replacement with insulin
D. methadone
E. a pulmonary artery catheter insertion
Explanation: The correct answer is C. This patient is suffering from diabetic ketoacidosis (DKA) caused by a severe deficiency of insulin. Clinical symptoms include coma, rapid and shallow breathing, high serum glucose levels, and metabolic acidosis. The immediate management of this patient includes intravenous fluid replacement and insulin infusion. When laboratory results return, electrolyte imbalances must also be corrected.A chest x-ray (choice A) would be complementary to a complete the evaluation of any comatose patient. In this patient with a picture of diabetic ketoacidosis, a chest x-ray would be a secondary concern. The first priority is intravenous fluid replacement and insulin therapy.Endotracheal intubation (choice B) is not necessary at this point as the patient has a normal oxygen saturation. Adequacy of respiration will need to be reassessed when the arterial blood gas results are available. The first priority is intravenous fluid replacement and insulin therapy.Methadone (choice D) is used to treat heroin dependency. A pulmonary artery catheter (choice E) is not yet necessary as the patient is at the present time hemodynamically stable. The first priority is intravenous fluid replacement and insulin therapy.
A 45-year-old man comes to the clinic for a follow-up visit for hypercholesterolemia. On the previous visit, you placed him on a diet to lower his cholesterol. Now he tells you that he was following the diet, although he does not like it. At the same time he expresses concern that because his father died of a heart attack, dietary changes might not be sufficient for him. He hands you an article that he downloaded from the Internet extolling the virtues of a new cholesterol-lowering drug. You promise to look at the article and tell the patient what you think about it during his next visit in 3 months. The article describes a double-blind clinical trial in which patients with cholesterol levels over 240 were assigned to 1 of 3 groups: diet change only, drug only, or diet change and drug combined. Patients were followed over a 6-month period, and changes in cholesterol level from baseline was computed. The results of the study are presented in the table below. The drug was also shown to have significant side effects in 10% of the patients taking the drug. Based on this article, your recommendation to the patient should be A. because there is no difference between the effects of dietary change or taking the drug, the patient can choose which one he prefers
B. diet alone is sufficient and adding the drug will not provide enough clinical advantage to warrant the risk of the side effects
C. studies found on the Internet are not a good source of information for making treatment decisions
D. taking the drug by itself has sufficient clinical merit, so that dietary change is not required
E. taking the drug either with or without dietary change has sufficient clinical effect to merit giving the patient a prescription
F. the drug should be taken, but only in conjunction with dietary change
G. the results of this study may not apply to this patient and a 3-month trial dosage of the drug should be given to see what effect it has
Explanation: The correct answer is B. All three conditions show a lowering of cholesterol levels and the p-values indicate statistically significant differences among all three groups. However, the magnitude of the differences among the groups means that these differences are not clinically significant. Changes of 1 or 2 points in cholesterol levels are unlikely to be clinically meaningful. Because dietary change provides a notable lowering of cholesterol levels and avoids the possible side effects of the drug, this is the therapeutic option that gives the best benefit/risk ratio. Note that, of course, the physician should discuss with the patient his concerns that diet alone is not sufficient and explain the reasoning for this decision in detail.Because there is no difference between the effects of dietary change or taking the drug, the patient can choose which one he prefers (choice A), taking the drug by itself has sufficient clinical merit, so that dietary change is not required (choice D), taking the drug either with or without dietary change has sufficient clinical effect to merit giving the patient a prescription (choice E), and the drug should be taken, but only in conjunction with dietary change (choice F) are all incorrect because the three groups are statistically significant; however, not clinically significant.Studies found on the Internet are not a good source of information for making treatment decisions (choice C) is incorrect, because although everything on the Internet cannot be taken at face value, there are a number of excellent sites that publish valid, important medical information. The fact that the article was from the Internet, by itself, does not invalidate the article as a source of information.The results of this study may not apply to this patient and a 3-month trial dosage of the drug should be given to see what effect it has (choice G) is incorrect, because although the patient may have particularities which make the effects on him different than the published study, the study results should be taken as accurate, unless and until an individual patient's experience proves differently. Otherwise, all research would be useless and every drug would have to be tested on every patient.
A 47-year-old woman comes to the office with newly diagnosed type 2 diabetes mellitus for a follow-up visit regarding laboratory studies that you had ordered. She has no complaints at this time. Her temperature 37 C (98.6 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and weight is 116 kg (255 lb). Visual acuity is 20/20 in both eyes. Her hemoglobin A1C is 6.0% and her fasting blood glucose is 132 mg/dL. During your discussion with her, she relates that her father had diabetes and "went blind." She asks you if she should go to an ophthalmologist. The most appropriate response is: A. "Good visual acuity is an accurate predictor of the absence of diabetic retinopathy."
B. "I will perform yearly funduscopic exams and will refer you for ophthalmology consultation at the first sign of diabetic retinopathy."
C. "Ophthalmology consultation is recommended 5 years after the diagnosis of diabetes and yearly thereafter."
D. "With well-controlled diabetes you will prevent diabetic visual complications making a visit to an ophthalmologist unnecessary at this point."
E. "Yearly ophthalmology appointments should begin now."
Explanation: The correct answer is E. Yearly eye exams by an ophthalmologist are recommended for all patients with type 2 diabetes mellitus beginning at the time of diagnosis. Good visual acuity is not a predictor of the presence or absence of diabetic retinopathy (choice A).Funduscopic exams (choice B) should be a part of a primary care physician's evaluation of a patient with diabetes mellitus; however, the standard of care for diagnosis and treatment of diabetic retinopathy is under the care of an ophthalmologist. Young patients who are newly diagnosed with type 1 diabetes may delay ophthalmology consultation for 5 years in the absence of visual complaints, but this does not apply to type 2 patients (choice C).Good control of diabetes is important in preventing diabetic retinopathy; however, some patients will have diabetic retinopathy despite excellent control (choice D). Furthermore, diabetic patients are more likely to have other ocular diagnoses such as cataracts and glaucoma that are more easily diagnosed and managed by an ophthalmologist.
You are caring for a patient in the intensive care unit who was admitted 2 hours earlier with diabetic ketoacidosis. She is a 19-year-old girl with no known medical problems prior to this admission when her parents brought her in with abdominal pain, nausea, vomiting, and mild confusion. On admission her laboratory results were as follows:Sodium 129 mEq/dL
Potassium 5.5 mEq/dL
Chloride 88 mEq/dL
Bicarbonate 12 mEq/dL
Urea nitrogen, serum 51 mg/dL
Creatinine 2.0 mg/dL
Glucose 697 mg/dL
An insulin drip was started at 11 U/hr and intravenous fluids were started at 250 cc/hr. Two hours later, laboratory studies show:Sodium 132 mEq/dL
Potassium 4.0 mEq/dL
Chloride 89 mEq/dL
Bicarbonate 13 mEq/dL
Urea nitrogen, serum 41 mg/dL
Creatinine 1.9 mg/dL
Glucose 277 mg/dL
Shortly after these laboratory results return, the patient becomes unresponsive. Papilledema is observed bilaterally. The most likely explanation for the patient's rapid deterioration is A. arterial thrombosis associated with diabetic ketoacidosis
B. overlooking of toxic screen in patients initial evaluation
C. rapid lowering of serum glucose
D. use of a relatively hypertonic solution for rehydration
E. worsening lactic acidosis and tissue ischemia
Explanation: The correct answer is C. The target for lowering serum glucose is approximately 50-100 mg/dL/hour. More aggressive lowering of the serum glucose can result in cerebral edema. This is because the CSF glucose decreases more slowly than the serum glucose. If the serum glucose is lowered too rapidly, the CSF fluid is relatively hypertonic compared to the serum. Therefore, water will enter the CSF creating edema. Arterial thrombosis (choice A) occurs with increased frequency in DKA. This can manifest as MI, ischemic limbs, or stoke. The fact that this patient has papilledema suggests that edema is more likely than stroke. This patient's age also makes stroke less likely.Toxic screening for drugs should be part of the initial evaluation of a patient with altered mental status. This patient has an anion gap acidosis with an elevated glucose and likely does have DKA. Therefore, a toxic drug screen (choice B) is not the best answer.Normal saline (choice D) is an appropriate solution for rehydration in this patient. Although the patient's sodium is 129 mEq/dl on admission, when corrected for the elevated glucose, the sodium is 139 mEq/dL. Remember that these patients are very dehydrated on admission and need to be volume resuscitated.Lactic acidosis (choice E) can occur in patients with DKA from prolonged dehydration, infection, or tissue hypoxia. One would suspect that if this patient had a lactic acidosis on admission that it would correct with proper DKA management. You would not expect brain herniation from lactic acidosis.
A 45-year-old woman returns to your office to discuss the results of "blood tests" drawn 3 days earlier when she was complaining of fatigue, weight loss, frequent urination, and blurred vision for the last several weeks. She is a non-smoker and drinks 1 glass of wine per week. She had no past medical or surgical history and a complete physical examination 3 days earlier was unremarkable including a blood pressure of 130/72 mm Hg. Laboratory studies show: Based on these studies, you decide to begin treatment with rosiglitazone. At this time, the most important additional study to perform is A. alanine aminotransferase and aspartate aminotransferase
B. electrocardiogram
C. free thyroxine and T3 reuptake
D. 1-hour glucose tolerance test
E. 24 hour urine protein collection
Explanation: The correct answer is A. This patient has type II (adult-onset) diabetes, which has been diagnosed by a fasting glucose over 200 mg/dl and classic symptoms, including weight loss, blurred vision, and polyuria. The class of drugs known as thiazolidinediones, which includes rosiglitazone (Avandia) and pioglitazone (Actos) are often used as initial monotherapy. The mechanism of action is through enhancing insulin sensitivity of peripheral tissues. However, these medications have been shown to cause liver toxicity. Therefore, it is recommended to check liver enzymes before initiating therapy and every other month for the first year of therapy. EKG (choice B) is not indicated as she has no cardiac complaints, no cardiac history, and is normotensive. Given her complaints of fatigue and weight loss, a thyroid disorder was a possibility in your workup. However, given her normal TSH, further thyroid studies (choice C) are not necessary at this time.1-hour glucose tolerance test(choice D), is no longer used as a method for diagnosing diabetes except as a screening test during pregnancy. The patient's fasting glucose of 206, along with her classic symptoms are enough to make the diagnosis.It is important to screen all diabetic patients for renal disease. Though screening for microalbuminuria is indicated, it is best performed by a spot urine microalbumin/creatinine ratio, instead of a 24 hour urine test(choice E).
A 52-year-old man comes to the clinic because he has been feeling weak and dizzy for the past several days. He also tells you that at the same time he feels somewhat restless and has had a mild headache. His past medical history is significant only for some mild chronic low back pain for which he occasionally takes acetaminophen. His temperature is 37.0 C (98.6 F), blood pressure is 128/78 mm Hg, pulse is 78/min, and respirations are 18/min. Physical examination shows diffuse hyporeflexia and scant basilar crackles in the lungs. Laboratory studies show a leukocyte count of 8,900mm3, hematocrit 40%, platelets 295,000mm3, sodium 126 mEq/L, potassium 3.8 mEq/L, bicarbonate 18 mEq/L, blood urea nitrogen 9 mg/dL, creatinine 0.6 mg/dL, glucose 115 mg/dL, serum osmolality is 258 mOsm/kg (normal 280), and urine osmalality is 150 mmol/L. A chest x-ray shows a 4-centimeter right upper lobe mass and mediastinal adenopathy. The most appropriate next step in management is to A. admit the patient to the hospital and start an infusion of hypertonic (3%) saline until serum sodium normalizes
B. prescribe demeclocycline 150 mg orally 4 times per day, then follow up in 2 weeks with an oncologist
C. refer the patient to cardiothoracic surgery for a lung biopsy
D. restrict the patient to 1500 mL of water per day and obtain CT scan of the chest
E. schedule the patient for the next available oncology appointment
Explanation: The correct answer is D. This patient is presenting with a classic syndrome of inappropriate antidiuretic hormone secretion (SIADH). He has hyponatremia with elevated urine osmolality in the presence of decreased serum osmolality. The clinical symptoms are often vague like his, until more serious seizures or coma present. One of the most common causes of SIADH is small cell cancer of the lung, which he most likely has. The mainstay of treatment is with fluid restriction once the serum sodium level is greater than 125 mEq/L. If the patient's initial sodium is less than 125 mEq/L, then treatment with 0.9% normal saline or possibly even more hypertonic solutions (choice A) may be necessary. It is important not to correct the sodium level too quickly or a deadly syndrome known as central pontine myelinolysis may result. The actual appropriate rate is controversial. However, some recommend a rate of less than 0.5 mmol/L/hr. A CT scan of the chest will also be helpful to both the surgeon and oncologist.Demeclocycline is a medication that actually has nephrogenic diabetes insipidus (the opposite of SIADH) as one of its side effects by blocking the action of antidiuretic hormone. This medication is often adjunctive in the treatment of SIADH. However, you would not simply want to follow up with the patient in 2 weeks (choice B). They need much more vigilant care, as further hyponatremia can result in severe neurologic sequellae.Similarly, a lung biopsy (choice C) and a referral to an oncologist (choice E) will certainly be eventually required in this patient. However, treating the hyponatremia is of prime importance.
A 57-year-old woman comes to your office because she is frustrated about the control of her diabetes. She insists that she has been compliant with her diet but her sugars continue to be poorly controlled. Her current insulin regimen is as follows: 14 units NPH and 6 units regular insulin 30 minutes prior to breakfast, 8 units regular insulin 30 minutes prior to dinner, and 10 units NPH insulin before bedtimeShe has brought along a log of her sugars.DAY Sunday Monday Tuesday Wednesday Thursday Friday Saturday
8a.m.** 230* 188 195 197 210 150 306
11a.m. 133 120 100 179 122 120 111
4p.m. 99 103 129 113 147 133 89
9p.m. 300 198 145 139 306 167 203
*Numbers reflect glucose in mg/dl **8 a.m. sugars are fasting. The most appropriate changes to this patient's insulin regimen would include A. decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH insulin
B. increasing bedtime NPH insulin and increasing dose of pre-dinner regular insulin
C. increasing NPH insulin and regular insulin doses prior to breakfast
D. increasing pre-breakfast regular insulin and increasing pre-dinner regular insulin
E. increasing pre-dinner regular insulin dose only
Explanation: The correct answer is B. This patient has blood sugars which are poorly controlled in the morning and at 9 p.m. Fasting sugars are a reflection of night time NPH doses while late morning sugars are a reflection of a.m. regular doses. Evening sugars reflect dinner time regular insulin. The approximate onset of action, peak effect, and duration of action of NPH insulin and regular insulin are shown below:Type Insulin Duration of action Onset of Action (hr) Peak Effect Peak Effect
Regular 0.5-1 2-4 4-6
NPH 2-4 8-14 16-24
Decreasing pre-breakfast regular insulin and increasing pre-breakfast NPH insulin (choice A) would increase 11 a.m. sugars and decrease 4 p.m. sugars. Increasing NPH insulin and regular insulin doses prior to breakfast (choice C) would be reflected in 11 a.m. and 4 p.m. sugars respectively.Increasing pre-breakfast regular insulin and increasing pre-dinner regular insulin (choice D) would be reflected in 11 a.m. and 9 p.m. sugars respectively.Increasing pre-dinner regular insulin dose only (choice E) would reduce 9 p.m. sugars only.This question might seem confusing, but when confronted with a question that requires that you adjust a patient's insulin regimen it is helpful to answer the question without looking at any answer choices. You could then simply match your answer with the answer choices. Again, remember that a.m. regular insulin will control glucose levels after breakfast. NPH insulin given in the morning will peak around lunch time and will be reflected in post-lunch sugars. Pre-dinner regular insulin will obviously help you with night time or post-dinner sugars and night time NPH will help you control overnight sugars. If you remember this, this question becomes much less overwhelming.
A 60-year-old man with diabetes mellitus, hypertension, hyperlipidemia, and chronic renal insufficiency is admitted to the hospital because of lightheadedness. His medications include NPH insulin, amlodipine, and simvastatin. He is allergic to penicillin to which he gets an angioedema. His temperature is 37.1 C (98.8 F), blood pressure is 98/65 mm Hg, pulse is 87/min, and his respiratory rate is 22/min. On exam, he is ill appearing. His cardiac rhythm is regular and breath sounds are clear bilaterally. His abdominal exam is benign. A chest radiograph shows clear lungs. An electrocardiogram shows a sinus rhythm with peaked T waves. Laboratory studies show a serum sodium of 134 mEq/L, glucose of 98 mg/dL, and potassium of 6.2 mEq/L. The most appropriate intervention at this time is A. administration of glucose, orally
B. administration of insulin and glucose, intravenously
C. administration of furosemide, orally
D. administration of ringers lactate, intravenously
E. administration of sodium chloride, intravenously
Explanation: The correct answer is B. Hyperkalemia with electrocardiographic changes (peaked T waves) requires immediate medical treatment to prevent the onset of hyperkalemia-induced dysrhythmias. Administration of insulin intravenously causes serum potassium to move intracellularly, acutely reducing serum potassium. Glucose is co-administered to prevent insulin-induced hypoglycemia.Oral glucose (choice A) is of no utility in the treatment of hyperglycemia. Even when insulin is used for the treatment of hyperkalemia, glucose should be co-administered intravenously.Oral furosemide (choice C) is an appropriate choice for the long-term treatment of hyperkalemia, i.e., once the acute hyperkalemia has been treated. Interventions such as insulin and glucose simply cause the potassium to shift intracellularly. Its excretion can then be promoted by administration of diuretic agents such as furosemide.Ringers lactate (choice D) should be avoided with hyperkalemic patients since it contains potassium as a constituent (4 mEq/L).Sodium chloride (choice E) is not useful in the management of hyperkalemia.
A 61-year-old woman with chronic renal insufficiency due to long-standing diabetes mellitus comes to the office with a fever, cough, shaking chills, and fatigue. She has long-standing diabetes mellitus with her last hemoglobin A1C being 9.1%, BUN 51 mg/dL, and creatinine 2.1 mg/dL. A chest radiograph demonstrates a right lower lobe infiltrate. Oral antibiotics are prescribed for the patient. The most correct statement concerning a diabetic patient with an infectious process is: A. Antimicrobial dosing must be adjusted due to decreased liver function
B. Antimicrobial dosing must be adjusted due to decreased renal function
C. Diabetics have the same epidemiology of pulmonary infections as non-diabetics
D. It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics
E. Oral antibiotics are not efficacious for treating pneumonia in diabetics
Explanation: The correct answer is B. All drugs (substances in general) are eliminated from the body by means of either renal or hepatic clearance or both. This is one of the most important concepts known by physicians. Almost every patient that presents to inpatient medical services today has some impairment of one or both of these mechanisms. This must be kept in mind when prescribing any drug. In the case of this patient, renal antibiotic dosing schedules for variable renal function are available to every student and house officer and should be consulted regularly. This patient has a creatinine of 2.1 mg/dL, reflecting abnormal renal function. Antimicrobial dosing must be adjusted due to decreased liver function (choice A), although true as a general rule, is not particularly relevant to diabetics since their disease has no impact on liver function. We have no specific evidence that this patient has impaired hepatic function. Diabetics have the same epidemiology of pulmonary infections as non-diabetics (choice C) is incorrect as diabetics are more likely to suffer from Staphylococcus aureus and fungal pneumonia.It is more common for diabetics to have lower lobe pneumonia when compared to non-diabetics (choice D) is incorrect. Although certain patient populations tend to have anatomical variation in the location of their pneumonia, the common relationship between all of them is that they suffer from some sort of aspiration. Examples include intubated patients on mechanical ventilation and alcoholics. Diabetics are not included in this group. Oral antibiotics are not efficacious for treating pneumonia in diabetics (choice E) is false. Oral antibiotic efficacy is determined by the causative organism and location of the infection. Some specific dysfunctions such as gastric achlorhydria or bowel obstruction may interfere with oral efficacy, but not simply the presence of diabetes. Being a diabetic may make one prone to more malignant infections. There is no data that initial treatment of community acquired pneumonia in diabetics should be any different when compared to non-diabetics.
A 65-year-old woman comes to the clinic for a follow up visit after being diagnosed with type II diabetes mellitus. She is obese with a history of hypertension, hyperlipidemia, and osteoarthritis. Despite a 3-month trial of diet and exercise, her weight has increased by 3 pounds. In addition, her hemoglobin A1C has increased from 7.8% to 9.0% and her fasting blood sugar ranged from 167-188 mg/dL on the glucometer she now uses at home. With the exception of an elevated glucose, her laboratory results are within normal limits. The most appropriate pharmacotherapy for this patient is A. Acarbose
B. Chlorpropamide
C. insulin NPH at bedtime
D. insulin 70/30 BID
E. metformin
Explanation: The correct answer is E. Metformin acts predominately to decrease hepatic glucose production in the liver. It is an excellent choice for obese patients with diabetes because it promotes modest weight loss by actually decreasing the amount of insulin necessary because of decreased glucose produced by the liver. It is an appropriate drug for monotherapy or combination therapy of diabetes. It should not be used in patients with renal failure or those patients who are 80 years of older (creatinine clearance decreases with age) because or the risk of lactic acidosis. When metformin is used correctly, complications are uncommon. Because the amount of insulin secreted is not increased, it does not cause hypoglycemia.Acarbose (choice A) is an alphaglucosidase inhibitor. It works by decreasing the rate of glucose entry into the blood stream, thereby preventing some of the post prandial hyperglycemia. Acarbose has been shown to give a slight decrease in hemoglobin A1C concentrations. In clinical practice, these drugs are poorly tolerated because of gastrointestinal side effects such as diarrhea, bloating, and gas. Chlorpropamide (choice B) is a first-generation sulfonylurea. It works (as do all drugs in the sulfonylurea class) by binding to a receptor on the beta cells of the pancreas and stimulating insulin secretion. This class of drugs can be used as first-line treatment or can be used in combination with other medications. Chlorpropamide is rarely used today because of its propensity to cause more hypoglycemia than newer drugs in the class.Patients on multiple medications who continue to have poor glycemic control can be tried on a bedtime dose of NPH insulin. (choice C). If this is not effective, then twice a day injections with 70/30 should be added.Insulin 70/30 (choice D) is typically used only if poor control is achieved with oral agents. Obviously, most patients would prefer to take medication by mouth rather than injecting themselves with insulin. An exception to this would be a type II diabetic who presents with symptoms of hyperglycemia such as weight loss, polyuria or polydipsia. These patients can be started on insulin as initial therapy. Above imformation from Clinical Geriatrics "Improving Disease Management with New Treatments for Type 2 Diabetes Mellitus" Volume 8, number 7, June 2000.
A 63-year-old man comes to the office because of "problems seeing." He says that his wife is making him "get some help" because he got into a minor car accident last night, and it was his fault because he had difficulty seeing. His vision is "fine" during the day, but he is basically "blind as a bat" when it is dark. He admits to an "occasional bottle of vodka." He has dry skin with multiple, diffuse areas of hyperkeratosis. His condition would most likely have been prevented by supplementation with A. niacin
B. vitamin A
C. vitamin B1
D. vitamin B12
E. vitamin C
Explanation: The correct answer is B. This patient most likely has a vitamin A (retinoic acid) deficiency, which is characterized by night blindness and dry, hyperkeratotic skin. It can progress to conjunctival dryness, corneal ulceration, and necrosis. It occurs in patients with malabsorption or proteinuria, liver disease, alcoholics, and those receiving total parenteral nutrition (TPN).Niacin (choice A) deficiency, which is often called pellagra, is characterized by diarrhea, dementia, and dermatitis. It occurs in individuals with a high intake of maize (corn). It is not associated with night blindness.Vitamin B1 (thiamine) deficiency (choice C), which is often called beri-beri, is characterized by high output heart failure and central nervous system disturbances (Wernicke-Korsakoff syndrome). Wernicke-Korsakoff syndrome occurs in alcoholics and is associated with nystagmus, ataxia, confabulation, and retrograde amnesia. It is not associated with night blindness.A deficiency of vitamin B12 (choice D) is associated with megaloblastic anemia and peripheral neuropathy. It is not associated with night blindness. It occurs in individuals with pernicious anemia, postgastrectomy, and those with intestinal organisms or ileal abnormalities. A deficiency of vitamin C (choice E), which is often called scurvy, is characterized by easy bruising, perifollicular hemorrhages, purpura, poor wound healing, bone lesions, and emotional changes. It is not commonly associated with night blindness. It occurs in individuals with diets devoid of citrus fruits and vegetables.
An 11-year-old girl with insulin-dependent diabetes mellitus is brought to the emergency department by a friend's father because of severe abdominal pain and vomiting for the past 12 hours. The friend's father says that she has been complaining of mild stomach "cramps" and "thirst" for the past few days, but nothing this extreme. When he leaves the room, she reluctantly admits that she has not been taking her insulin because she is mad at her parents for going away to Europe and "leaving her" for 5 days. Her blood pressure is 100/70 mm Hg, pulse is 98/min, and respirations are 30/min. Physical examination shows dry skin and mucus membranes and diffuse abdominal pain. Laboratory studies show:Serum
Glucose 550 mg/dL
Sodium 138 mEq/L
Potassium 5.8 mEq/L
Chloride 94 mEq/L
Bicarbonate 10 mEq/L
Intravenous isotonic saline and insulin are given and she is admitted to the pediatric intensive care unit for careful monitoring and management. Two hours later, potassium is added, as her glucose and potassium levels begin to drop rapidly. All seems to be going well until half an hour later when the nurse runs over to you frantically saying that the patient suddenly complained of a headache, began to vomit, and became "completely disoriented." You rush to the bedside to find her obtunded. The most appropriate immediate management is to A. add more potassium to the intravenous solution
B. add phosphate to the intravenous solution
C. add sodium bicarbonate to the intravenous solution
D. administer a bolus infusion of mannitol
E. increase the dose of insulin
Explanation: The correct answer is D. This patient has diabetic ketoacidosis (DKA) and has most likely developed cerebral edema, which should be treated with mannitol and dexamethasone. If this is not effective, hyperventilation should be induced. DKA is characterized by hyperglycemia, osmotic diuresis, metabolic acidosis, and elevated ketones. The typical clinical presentation is abdominal pain, nausea, vomiting, polyuria, and lethargy. It is usually precipitated by an infection, stress, a cessation of insulin intake, or surgery. The initial treatment includes insulin and isotonic saline or Ringer's lactate. As glucose and potassium levels begin to fall, potassium and glucose solutions must be given. Bicarbonate is given to patients with severe acidosis. If the glucose level is corrected too rapidly and glucose is not added to the intravenous fluids as the levels fall below 300 mg/dL, cerebral edema may develop. Clinically, cerebral edema manifests as acute altered mental status, vomiting, and a headache. A CT scan is used to make the diagnosis. Adding more potassium to the intravenous solution (choice A) would not be the appropriate management of cerebral edema, which requires mannitol. This patient's acute complication is inconsistent with hypokalemia, which is typically associated with cardiac arrhythmias.Adding phosphate to the intravenous solution (choice B) is an important part of the treatment of DKA. However, this patient is most likely suffering from cerebral edema, which is a life-threatening condition that requires rapid treatment with mannitol, not phosphate. Patients with hypophosphatemia typically complain of muscle weakness.Sodium bicarbonate (choice C) is typically used in severely acidotic patients with hypotension. It is not used to treat cerebral edema.Increasing the dose of insulin (choice E) is incorrect because this patient has cerebral edema, which is most likely caused by the rapid fall of glucose, and so you would not want the glucose levels lowered even more rapidly.
A 23-year-old man is admitted to the medical services for dehydration. He had just completed a marathon that afternoon and was brought to the hospital by his sister who found him to be lethargic and confused. His sister informs you that he has been training very vigorously for the marathon and completed the marathon in near-record time by not stopping for rehydration at all of the available rest stops. On examination, the patient is a well-developed man. He is speaking using unclear words and is warm to the touch with stable vital signs. His skin is very dry and his lips are chafed. His serum sodium is 163 mEq/L. The result is confirmed with the laboratory. The most appropriate management at this time is A. intravenous half normal saline repletion
B. intravenous lactated ringers repletion
C. intravenous normal saline repletion
D. oral free water repletion
E. oral thiazide diuretics
Explanation: The correct answer is D. This patient has hypernatremia as a consequence of insensible free water losses. He needs free water repletion with one half the free water deficit being given in the first 12 hours and the remaining half over the next 24 hours. The serum sodium should fall by no more than 0.5mEq/L/hour (12 mEq/day). Intravenous half-normal saline repletion (choice A) will worsen the condition. Although there is more free water in this preparation, the added sodium will likely worsen this patient's condition. There is no role for intravenous lactated ringers repletion (choice B) in correcting hypernatremia since it has a similar sodium content as normal saline. Intravenous normal saline repletion (choice C) will aggravate the condition by providing only some free water and the remainder sodium. This is used to replete some forms of hyponatremia.Oral thiazide diuretics (choice E) are often a treatment for hypernatremia when salt sodium excess is the primary problem. This can occur with hypertonic dialysis solutions.
A 32-year-old woman comes to the office because of palpitations and anxiety for a few months. She further complains that, "My right eye is bulging out of my head and I see double." Examination reveals visual acuity of 20/20 in both eyes, exophthalmos of the right eye, and redness in both eyes, worse in the left eye. You order a sensitive thyroid stimulating hormone test, which comes back at 0.1 U/mL. At this time the most correct statement about this patient's condition is: A. Cigarette smoking has been shown to increase the severity of exophthalmos in this disease
B. Diplopia observed in this condition is from