Pharm - Review Qs

Question 1

When a patient is suffering from myxedema coma the most appropriate treatment would be to:
(A) Stop using levothyroxine
(B) Administer oral propylthiouracil
(C) Administer intravenous liothyronine
(D) Administer oral levothyroxine
(E) Administer oral beta-blockers

Answer 1

C

Question 2

If a patient using methimazole for hyperthyroidism develops agranulocytosis, the best course of action would be to:
(A) Continue using the same dose of methimazole
(B) Stop methimazole and start propylthiouracil
(C) Stop antithyroid drugs and use radioiodine treatment
(D) Add carbimazole
(E) Increase the dose of methimazole

Answer 2

C

Question 3

A common side effect associated with the use of radioiodine to treat Graves’ disease is:
(A) Angina
(B) Hypothyroidism
(C) Increased risk of liver cancer
(D) Leukemia
(E) Increased risk of coronary artery disease

Answer 3

B

Question 4

You decide to treat your hyperthyroid patient with an agent that inhibits thyroid hormone synthesis, and inhibits peripheral conversion of thyroxine to triiodothyronine. Which one of the following drugs is most appropriate?
(A) Lithium carbonate.
(B) Amiodarone.
(C) Propylthiouracil (PTU)
(D) Propranolol.
(E) Methimazole.

Answer 4

C

Question 5

A 50-year-old female complains of bone pain, most severely in the hips. Blood work is normal except for severely elevated alkaline phosphatase. X-ray indicates a thickening of the cortex, increased trabecular markings and expansion in the size of the bone, with variable degrees of gross bone deformity. Bone scans indicated increased bone metabolism. Which one of the following is the most likely diagnosis?
A. Primary hyperparathyroidism
B. Pseudohypoparathyroidism
C. Secondary hypoparathyroidism due to renal insufficiency
D. Osteomalacia
E. Paget’s disease

Answer 5

E
Paget’s disease- alkaline phosphatase and bone scans indicate increased bone
metabolism; X-ray features are typical of Paget’s disease.

Question 6

A 36-year-old male presents with diffuse bone pain and significant weight loss. Blood work indicates severely elevated leukocytes, anemia, hypercalcemia, with alkaline phosphatase. PTH levels are suppressed. X-ray indicates diffuse osteopenia.
A. Primary hyperparathyroidism
B. Pseudohypoparathyroidism
C. Secondary hyperparathyroidism due to renal insufficiency
D. Hypercalcemia of malignancy
E. Osteomalacia

Answer 6

D
Elevated leukocytes indicate potential lymphoma/leukemia; diffuse bone pain with osteopenia plus elevated alkaline phosphatase and depressed PTH indicated potential bone metastases due to PTHrP release.

Question 7

A pregnant patient presents with weakness and muscle fatigue, heat intolerance, tachycardia and nervousness. Laboratory tests reveal decreased TSH and increased free T4. Which one of the following treatments is most appropriate?
(A) Ipodate sodium.
(B) Thiocyanate.
(C) Radioactive iodine (131I).
(D) Levothyroxine.
(E) Propylthiouracil (PTU).

Answer 7

E

Question 8

When a patient presents with both a hypothyroid condition and a cardiovascular disorder such as angina, the most appropriate treatment would be:
(A) Stop using levothyroxine.
(B) Use beta-blockers to treat his/her hypothyroid condition.
(C) Cautiously use levothyroxine by initially starting at lower doses.
(D) Use propylthiouracil.
(E) Use liothyronine sodium.

Answer 8

C

Question 9

A 45 year-old female complains of weight loss, rapid heartbeat, heat intolerance and hand tremors. The most likely diagnosis would be:
(A) Hashimoto’s thyroiditis.
(B) Grave’s disease.
(C) Secondary hypothyroidism.
(D) Cretinism.
(E) Addison’s disease.

Answer 9

B

Question 10

A 54-year old male who has suffered from asthma for 30 years (treated with intermittent oral prednisolone) was admitted for acute onset chest pain (right side) accompanying severe bronchitis. X-ray indicates acute rib fracture and evidence of healed fractures as well as decreased bone density. Blood work was normal. Rib fracture and bronchitis were treated symptomatically. Which one of the following is the most likely diagnosis?
A. Paget’s disease
B. Osteoporosis
C. Osteomalacia
D. Malabsorption syndrome
E. Secondary hypoparathyroidism due to renal insufficiency

Answer 10

B
Repeated rib fractures on exertion due to low bone density: caused by prolonged,
intermittent treatment with glucocorticoids

Question 11

A 62-year-old male presented with renal stones and complains of lethargy, polyuria, polydipsia and muscle weakness. Blood work reveals elevated plasma calcium and parathyroid hormone (PTH), decreased phosphate, normal creatinine and albumin. Plasma alkaline phosphatase and hydroxyproline were elevated. Urinary calcium excretion was increased. Which one of the following is the most likely diagnosis?
A. Pseudohypoparathyroidism
B. Primary hyperparathyroidism
C. Hypercalcemia of malignancy
D. Chronic renal failure
E. Secondary hyperparathyroidism due to renal insufficiency

Answer 11

B

Question 12

A 36-year-old female being treated for breast cancer presents with diffuse bone pain and significant weight loss. Blood work indicates severely elevated leukocytes, anemia, hypercalcemia, with increased alkaline phosphatase. Parathyroid hormone (PTH) levels are supressed. Xray indicates diffuse osteopenia. Which one of the following is the most likely diagnosis?
A. Pseudohypoparathyroidism
B. Primary hyperparathyroidism
C. Paget’s disease
D. Osteomalacia
E. Hypercalcemia of malignancy

Answer 12

E
Elevated leukocytes indicate potential
lymphoma/leukemia; diffuse bone pain with osteopenia plus elevated alkaline phosphatase and depressed PTH indicate potential bone metastases due to PTHrP release

Question 13

A 48 year-old male complains of tiredness, thirst, constipation and polyuria. Blood work indicates anemia, increased BUN and a large increase in creatinine and alkaline phosphatase, with normal glucose. Serum calcium and vitamin D are reduced, while phosphate and PTH are elevated. Upon Xray, there are indications of osteopenia and nephrocalcinosis. Which one of the following is the most likely diagnosis?
(A) Primary Hyperparathyroidism
(B) Pseudohypoparathyroidism
(C) Secondary hyperparathyroidism-due to renal insufficiency (D) Hypercalcemia of malignancy
(E) Osteomalacia

Answer 13

C

Question 14

A 78 year-old woman complains of chronic diarrhea and weakness. Blood work indicates low calcium, phosphate, vitamin D and plasma protein, with elevated levels of PTH. Xray indicates osteopenia. Which one of the following is the most likely diagnosis?
(A) Primary Hyperparathyroidism (B) Pseudohypoparathyroidism
(C) Malabsorption syndrome
(D) Secondary hyperparathyroidism (E) Hypercalcemia of malignancy

Answer 14

C

Question 15

A 40 year-old man with a history of severe ulcerative colitis has needed treatment with prednisone 25 mg a day for 4 months to control his disease. Which one of the following treatments should be initiated?
(A) Stop treatment with prednisone.
(B) Begin treatment with aldosterone.
(C) Increase the dose of prednisone.
(D) Begin treatment with an oral bisphosphonate.
(E) Begin treatment with fludrocortisone.

Answer 15

D
Begin treatment with an oral bisphosphonate. This patient is at high risk for bone loss because of his long term prednisone use and should be treated empirically with a medication such as alendronate to prevent further bone loss. Steroids are harmful in particular to the bone health of post-menopausal women but adversely effect both sexes, regardless of age or race. A dose of prednisone greater than 7.5 mg per day is considered greater than physiologic. Any course of steroids that are high dose given for more than 3 weeks should be considered to have suppressed the hypothalamic-pituitary-adrenal axis. Because of this, his prednisone cannot be stopped abruptly and must be tapered to prevent adrenal insufficiency.

Question 16

A 75 year-old hospitalized man is noted to have a very high serum calcium. PTH is undetectable and vitamin D levels are normal. PTHrP (PTH related protein) is elevated. What is the most likely diagnosis?
(A) Primary hyperparathyroidism
(B) Pseudohypoparathyroidism
(C) Hypercalcemia of malignancy
(D) Paget’s disease of bone
(E) Secondary hyperparathyroidism

Answer 16

C
Hypercalcemia of malignancy is the most likely cause of an elevated calcium in hospitalized patients. PTHrP (PTH related peptide) is a humoral marker released in malignancy that works like PTH to raise calcium levels. In this situation, PTH is low. PTH would be elevated in primary or secondary hyperparathyroidism. Pseudohypoparathyroidism would result in low serum calcium and Paget’s disease does not present in this manner.

Question 17

A 40 year-old female is found on routine labs to have a low calcium level. All of the following conditions could be responsible for this except:
(A) Magnesium deficiency
(B) Vitamin D deficiency
(C) Low albumin
(D) Secondary hyperparathyroidism
(E) Primary hyperparathyroidism

Answer 17

E

Question 18

A 70 year-old thin, caucasian man has a fall at home and breaks his hip. All laboratory studies performed to exclude an underlying cause for his condition, including PTH and vitamin D levels, are normal. Which medication would be the best choice for this patient to prevent future complications from his metabolic bone disorder?
(A) Alendronate
(B) Raloxifene
(C) Calcitriol
(D) Glucocorticoids
(E) Magnesium oxide

Answer 18

Alendronate is a bisphosphonate used to prevent fractures in osteoporosis. This patient has the diagnosis of osteoporosis on the basis of having sustained a non-traumatic fracture. Raloxifene is a selective estrogen receptor modulator and currently only used to treat osteoporosis in women.

Question 19

A 60 year-old female is found to have an elevated calcium level on routine lab work. Subsequent lab studies reveal low phosphorus and elevated PTH. If her underlying condition is left untreated, what is she most at risk for developing in the future?
(A) Vitamin D deficiency
(B) Osteoporosis
(C) Heart failure
(D) Hypocalcemia
(E) Malabsorption

Answer 19

B

Question 20

A 60 year-old female complains of sudden onset of back pain. She has a slim stature, history of early menopause (at 40 years of age), and decreased height. Blood work indicates normal calcium and phosphate, and increased alkaline phosphatase. X-ray indicates a compression fracture of the lumbar vertebra. Densitometry indicates significant decreases in lumbar spine and mild decreases of femur bone. Which one of the following is the likely diagnosis?
(A) Primary hyperparathyroidism
(B) Pseudohypoparathyroidism
(C) Malabsorption syndrome.
(D) Osteoporosis
(E) Osteomalacia

Answer 20

D

Question 21

A 22 year-old woman with history of primary adrenal insufficiency presented to the Emergency Department with complaint of nausea, vomiting and abdominal pain. Her blood pressure is 90/60 mmHg. Her chest x-ray shows a left sided pneumonia. Her blood work shows sodium level of 128 mEq/L (normal range: 125-145), and potassium of 5.6 mEq/L (normal range: 3.5- 5.0). Which one of the following is the most appropriate treatment?
(A) IV isotonic saline, D5W (5% dextrose in water), hydrocortisone 100mg IV Q8H, IV Abx
(B) Prednisone 80mg po Q8H
(C) Dexamethasone 1mg PO QD, IV isotonic saline, D5W, IV Abx
(D) Hydrocortisone 20mg in the morning 10mg in the evening
(E) Hydrocortisone 100mg QD, IV isotonic saline, D5W

Answer 21

A
This patient is in adrenal crisis. If the patient’s adrenal glands were functioning optimally they would have responded to this illness by increasing the amount of steroids produced. Since her adrenals are unable to mount a response to stress, she needs vigorous management with intravenous fluids, hydrocortisone and treatment of the precipitating illness.

Question 22

A 33 year-old woman with history of primary adrenal insufficiency treated with hydrocortisone at a dose of 10 mg in the morning and 5 mg in the evening, complains of sore throat with mild fever. She denies vomiting. Her blood pressure is normal. Her primary care physician has started her on an antibiotic. Which one of the following is the most appropriate treatment?
(A) IV isotonic saline, D5W (5% dextrose in water), hydrocortisone 100mg IV Q8H, IV Abx
(B) Prednisone 80mg po Q8H
(C) Dexamethasone 1mg PO QD, IV isotonic saline, D5W, IV Abx
(D) Hydrocortisone 20mg in the morning 10mg in the evening
(E) Hydrocortisone 100mg QD, IV isotonic saline, D5W

Answer 22

D
This patient has mild infection. Her blood pressure is normal. Doubling the dose of glucocorticoids is sufficient for mild infections. If she were vomiting or had symptoms consistent with acute adrenal insufficiency then she would have needed hospitalization.

Question 23

A 25 year-old woman presents to the Emergency Department with complaint of feeling bloated. She has a history of primary adrenal insufficiency. She is on prednisone and has been taking fludrocortisone at a dose of four 0.1 mg tablets daily for the last ten days. Her supine blood pressure is 170/99. She has mild to moderate edema of the legs. Her blood work shows a potassium level of 2.9 mEq/L (normal range: 3.5-5.5) and a sodium level of 148 mEq/L (normal range: 135-140). What is the cause of her present ailment?

Answer 23

This patient has been taking fludrocortisone at a dose that is far more than her prescribed dose. Fludrocortisone is used to treat mineralocorticoid deficiency in patients with primary adrenal insufficiency. The recommended dose is 0.1 mg to 0.2 mg once daily. This patient had been taking fludrocortisone at a daily dose of 0.4 mg for almost ten days. Mineralocorticoid excess causes hypernatremia, water retention, hypokalemia, hypertension and metabolic alkalosis.

Question 24

A 29 year-old man with history of congenital adrenal hyperplasia due to 21-hydroxylase deficiency is being evaluated for recurrent episodes of hyperkalemia for the last few months. He is being treated with Dexamethasone 0.75 mg once daily for the last six months. He is not taking any potassium supplements and eats a balanced diet. On physical examination his blood pressure was 100/70 mm Hg. Blood work showed: sodium 129 mEq/L (normal range 130-140), potassium 5.5 mEq/L (normal range 3.5-5.2), chloride 118 Meq/L (normal range 110-115) and CO2 18 (normal range 20-30 ). What change should be made in his medication to treat hyperkalemia?

Answer 24

Add a mineralcorticoid

In congenital adrenal hyperplasia due to 21-hydroxylase deficiency, there is deficiency of both glucocortioids and mineralocorticoids. This patient is being replaced with a glucocorticoid (dexamethasone) that has negligible mineralocorticoid effect. He is exhibiting signs of mineralocorticoid deficiency which include hyponatremia, volume depletion, hyperkalemia, hypotension and hyperchloremic metabolic acidosis. Addition of a mineralocorticoid (e.g. fludrocortisone) will reverse these changes and treat his hyperkalemia.

Question 25

5. A 20 year-old woman complains of recurrent episodes of lightheadedness and dizziness. On today’s visit her blood pressure is 105/80 mm Hg and her pulse is 80 beats per minute lying, and a blood pressure of 80/70 and a pulse of 100 beats per minute on standing up. She has mild darkening of the skin of face and arm. You suspect primary adrenal insufficiency. Her blood work is likely to show what Na and K state?

Answer 25

Hyponatremia, Hyperkalemia The laboratory abnormalities most commonly seen in patients with primary adrenal insufficiency are hyponatremia, hyperkalemia, anemia, eosinophilia and lymphocytosis. The hyponatremia and hyperkalemia are due to the lack of mineralocorticoid (aldosterone) effect on the distal renal tubule.

Question 26

A 58 year-old man is being evaluated for complaints of weight gain of 100 pounds over the last six months. He has also noticed weakness in his muscles and finds it difficult to climb stairs which he was able to do six months ago. He has also noticed easy bruising of his skin and violaceous stretch marks on his abdomen. He also has heart burn and uses antacid from time to time. On examination his blood pressure is 150/100 and Pulse of 88 per minute. He has increased deposition of fat around his abdomen and neck and has supraclavicular fat pads. His skin has numerous bruise marks and striae are noted on his abdomen. The patient has been on Prednisone 40 mg orally daily for the last nine months for treatment of bilateral orbitopathy due to Graves’ disease. Select the appropriate diagnosis for this patient

Answer 26

Iatrogenic Cushing syndrome

Question 27

A 22 year-old man has complaint of frequent episodes of nausea, vomiting, lightheadedness, weight loss of 20 pounds and generalized weakness over the last three months. He has been to the emergency room on three occasions for similar complaints. He states that he was treated with intravenous fluids on each occasion and felt better. On examination his blood pressure is 110/80 in a supine position and 90/70 in a standing position. You notice hyperpigmentation of skin and mucous membranes.You suspect primary adrenal insufficiency. What test will best help you to confirm the diagnosis of adrenal insufficiency in this patient?

Answer 27

Cosyntropin stimulation test The cosyntropin stimulation test, also known as ACTH stimulation test is performed by intramuscular or intravenous administration of 250 micrograms of cosyntropin. Plasma cortisol levels are measured at 0 and 30 minutes after the administration of cosyntropin. A normal response is defined by a cortisol level of greater than 19 micrograms/dl at 30 minutes after the injection.

Question 28

A 64 year-old woman has been having episodes of lightheadedness for the past week or so. She states that she nearly passed out on few occasions. She denied any complaints pertaining to fever, chills, chest pain, shortness of breath, nausea, vomiting or diarrhea. Her medical history is significant for chronic obstructive pulmonary disease (COPD). She states that she had been on prednisone 40 mg daily for about six weeks to treat exacerbation of her bronchitis, and stopped taking it abruptly about two weeks ago as she ran out of prescription. On examination she is found to have postural hypotension. The most likely cause of her illness is?

Answer 28

Acute adrenal insufficiency Acute adrenal insufficiency is precipitated by abrupt withdrawal of steroids. Patients taking high dose steroids for prolonged periods of time can have suppression of the hypothalamic pituitary adrenal (HPA) axis

Question 29

A 42 year-old man presents with episodes of fatigue and tiredness for the last six months. He denies any complaints of headaches, sweats, shakes, palpitations and heat or cold intolerance. His weight has been stable. On examination he appears to be a well-built male with normal body weight. His blood pressure is 175/100 mm of Hg and pulse 88/m and regular. The rest of the physical examination is unremarkable. Blood work shows no anemia and normal creatinine level. Serum electrolytes show a potassium level of 3.1 meq/L (normal range: 3.5-5.0 meq/L). What can be done further to help diagnose the underlying condition?

Answer 29

Obtain plasma aldosterone and renin level. Excess secretion of aldosterone causes hypertension and hypokalemia. Aldosterone excess can be checked by performing plasma aldosterone and renin levels. In states of primary hyperaldosteronism, plasma aldosterone to renin ratio is elevated (generally greater than 30) and requires further biochemical testing. If the aldosterone levels are elevated and non-suppressible then a radiologic study such as CT scan or MRI of the adrenal glands needs to be done. Ambulatory blood pressure monitoring would be indicated if the blood pressure was borderline high. 24 hour urine for free cortisol and creatinine would help in the diagnosis of Cushing’s syndrome. Weight gain and obesity are common features of Cushing’s syndrome. Pheochromocytoma typically presents with episodes of sweats palpitations, headaches and high blood pressure and is not associated with hypokalemia.

Question 30

A 24-year-old graduate student with type-1 diabetes mellitus is taking insulin glargine 32 units subcutaneously daily and insulin aspart 8 units with each meal. He is gaining weight and becoming overweight. His home blood glucose monitoring results demonstrate hypoglycemia at 2pm each afternoon. Other blood glucose levels are normal. The most reasonable approach would be: (A) Decrease dose of insulin glargine. (B) Eat an extra mid-afternoon snack daily. (C) Decrease pre-lunch dose of insulin aspart. (D) Change from insulin aspart to insulin regular. (E) Change from insulin glargine to NPH insulin before breakfast and at bedtime.

Answer 30

C If the insulin glargine dose was too high, the glucose level would fall overnight and the fasting glucose level would be low. Adding more calories by eating an extra afternoon snack would only further exacerbate the weight gain. Regular insulin with lunch could also cause afternoon hypoglycemia. Changing to NPH insulin would not help. NPH given before breakfast peaks in the afternoon, which would only make the afternoon hypoglycemia worse.

Question 31

``` An 80-year-old woman has newly diagnosed diabetes. She has received nutrition counseling. Her fasting blood glucose levels are normal, but after meals they rise into the high range. She sometimes eats 3 meals a day, and sometimes wakes up late and only eats 2 meals a day. She is not overweight. Other medical problems include arthritis, congestive heart failure requiring hospitalization twice over the past year, and osteoporosis. You suggest that she begin which one of the following? (A) Glyburide. (B) Metformin (C) Rosiglitazone (D) Exercise after each meal (E) Repaglinide ```

Answer 31

E Glyburide is most likely to cause hypoglycemia, especially fasting or after a skipped meal in an elderly woman whose fasting glucose level is not elevated. Metformin and rosiglitazone are contraindicated in the presence of congestive heart failure. Asking an 80 year old woman with arthritis and congestive heart failure to exercise three times daily is unrealistic. Repaglinide can be given with each meal and can control post-prandial hyperglycemia, and is less likely than glyburide to cause hypoglycemia.

Question 32

The primary mechanism of action of metformin is: (A) Decrease hepatic glucose production. (B) Increase insulin secretion. (C) Decrease dietary absorption of glucose. (D) Slow dietary absorption of carbohydrates. (E) Regulate the transcription of insulin-response genes by binding to nuclear peroxisome proliferator-activated receptors (PPAR-gamma)

Answer 32

A Sulfonylurea, repaglinide and nateglinide increase insulin secretion. Alpha glucosidase inhibitors slow carbohydrate absorption. Thiazolidinediones bind PPAR-gamma receptors that regulate transcription of specific genes.

Question 33

A 33-year-old obese woman with type 2 diabetes is taking metformin. Her blood glucose levels are mildly elevated. She calls the office and tells you that she has become pregnant. You should advise her to: (A) Stop the metformin and prescribe glyburide (B) Stop the metformin and begin insulin therapy. (C) Stop the metformin and prescribe rosiglitazone (D) Stop the metformin and prescribe increased activity and dietary counseling (E) Add glyburide

Answer 33

B All oral agents are contraindicated in pregnancy. Glycemic control is particularly important during pregnancy to prevent congenital malformations and other complications. Insulin should be used.

Question 34

A 45-year-old obese man with type 2 diabetes is being treated with metformin and insulin glargine. His fasting blood glucose levels and his levels before lunch are normal, but he has elevated levels before dinner and bedtime (he eats very little for breakfast). You should advise him to: (A) Add insulin aspart with each meal. (B) Stop the insulin glargine and begin 70/30 insulin before breakfast and dinner. (C) Stop the metformin and add rosiglitazone. (D) Add insulin aspart with lunch and dinner. (E) Increase the dose of insulin glargine.

Answer 34

D He does not need short-acting insulin with his small breakfast since after breakfast (pre- lunch) glucose levels are normal, but he does need short-acting insulin for lunch and dinner since his glucose levels rise after those meals. 70/30 insulin would add short-acting insulin for breakfast, which he does not need and could cause hypoglycemia. Increasing the dose of insulin glargine would cause hypoglycemia in the morning. Substituting rosiglitazone for metformin would not be expected to change overall control, and could cause further weight gain

Question 35

A 25 year-old medical student with type 1 diabetes is taking insulin glargine 24 units at bedtime, and insulin lispro with meals. She takes 10 units with breakfast, 4 units with lunch and 10 units with dinner. She checks her blood glucose levels before each meal and at bedtime. She awakens with hypoglycemia every morning. Other blood glucose values are normal. She is gaining weight, and now has a BMI (Body Mass Index) of 26 (overweight). The appropriate change in her treatment would be: (A) Decrease the dinner dose of lispro. (B) Eat a bedtime snack. (C) Decrease the dose of insulin glargine. (D) Discontinue insulin lispro and substitute insulin aspart. (E) Discontinue insulin glargine and substitute NPH insulin at bedtime (same dose).

Answer 35

C Only the insulin glargine is active the next morning, and so this dose of insulin is the only one that could cause her fasting hypoglycemia. Decreasing the dinner dose of lispro will only cause post-dinner hyperglycemia. Eating a bedtime snack might help, but would encourage further weight gain (and she needs to lose weight). Insulin lispro and aspart have the same kinetics, so substituting insulin aspart for lispro would not be expected to help the situation. NPH at bedtime would be more likely to cause hypoglycemia because of its peak effect in the early morning hours

Question 36

A thin 18 year-old college student, with no known medical problems, develops extreme thirst (polydipsia), frequent urination (polyuria), hunger (polyphagia), weight loss and symptoms she thinks represent the flu. She eats a very high carbohydrate diet (lots of pizza, soda, etc). She goes to student health, and they find that her blood glucose level is 450 mg/dl. She comes to you for an urgent consultation. She does not want to start insulin therapy (she does not like needles) The appropriate treatment would be: (A) Start a sulfonylurea drug and metformin, tell her to stop eating junk food, and instruct her on eating a healthy diet. (B) You instruct her on eating a healthy diet and start insulin glargine once a day. (C) You instruct her on eating a healthy diet and start 70/30 insulin twice a day. (D) You instruct her on eating a healthy diet and increase exercise. (E) You instruct her on eating a healthy diet and start insulin glargine once daily and insulin aspartwith each meal (4 injections daily).

Answer 36

E She has new onset type 1 diabetes and needs intensive insulin therapy. Oral agents should not be used in type 1 diabetes. Insulin glargine alone will not be sufficient. You need to prescribe a rapidly acting insulin to cover the carbohydrate loads of meals. 70/30 insulin twice a day is used in type 2 diabetes, and would not be able to adequately control meals and snacks in a college student.

Question 37

A 75 year-old obese gentleman with type 2 diabetes comes to you for initial consultation. He is taking a submaximal dose of metformin and low dose 70/30 insulin with breakfast and dinner. His glycemic control remains poor. Blood glucose levels remain elevated throughout the day. His renal function is quite poor and he is expected to need dialysis in the near future. The most appropriate change in his treatment would be: (A) Increase metformin to maximal dose. (B) Continue current medications and put him on the Atkins diet. (C) Discontinue 70/30 insulin and add glyburide (sulfonylurea). (D) Discontinue metformin and increase dose of 70/30 insulin. (E) Continue metformin and increase dose of 70/30 insulin.

Answer 37

D Metformin needs to be stopped in the presence of significant renal disease. Glyburide also should not be used with impending renal failure

Question 38

``` A 72 year-old obese gentleman has had type 2 diabetes for 5 years. You and a dietitian have counseled him to lose weight and increase his physical activity for the past 5 years but he gains a few pounds each year and remains inactive. He takes metformin and all his blood glucose levels are elevated. He does not have kidney or heart disease. All of the following are reasonable next steps except: (A) Add glyburide. (B) Add rosiglitazone. (C) Add insulin glargine once daily. (D) Stop metformin and add glyburide. (E) Add NPH insulin at bedtime. ```

Answer 38

D This patient needs combination therapy. Monotherapy with metformin or glyburide improves overall glycemia to an approximately equal extent. Therefore substituting one for the other would not be expected to improve hyperglycemia. Metformin should be continued in this obese patient.

Question 39

An 18 year-old thin college student comes to the emergency room with nausea, vomiting, extremely high blood glucose values (>800 mg/dl), dehydration and ketoacidosis. She is admitted for treatment with intravenous fluids and intravenous insulin. The next day the student is feeling much better. The diabetic ketoacidosis has resolved. She can now eat without nausea or vomiting and is no longer dehydrated. She was found to have a urinary tract infection and was placed on an oral antibiotic. Intravenous medications and fluids are being discontinued. Pregnancy test is negative. What medication regimen do you prescribe?

Answer 39

Insulin glargine once daily subcutaneously plus insulin aspart subcutaneously with meals. This patient has type 1 diabetes and requires basal and bolus insulin therapy. Oral agents are not used in type 1 diabetes.

Question 40

A thin 70 year-old retired Syracuse University professor is taking glyburide and insulin glargine. Blood glucose levels after meals remain high. Fasting glucose levels are normal. What change should you make in his therapy? (A) Increase the dose of insulin glargine (B) Add NPH insulin twice a day (C) Add insulin lispro with meals (D) Stop glyburide and add insulin lispro with meals (E) Add metformin

Answer 40

D Both A and B will cause hypoglycemia. This patient needs a rapidly acting insulin (i.e., insulin lispro, aspart or glulisine) with meals. There is no reason to continue glyburide since it has been insufficient to cover his meal time glycemic excursions. Metformin is given to obese patients and primarily decreases hepatic glucose production overnight, thereby decreasing fasting glucose levels.

Question 41

A 45 year-old overweight business executive is taking insulin glargine at bedtime and insulin lispro with meals. His fasting (morning) glucose levels are too low, requiring him to eat large breakfasts every day. His prelunch glucose levels are normal and he eats a mid-afternoon snack. His before dinner levels are usually normal and his bedtime levels are high. His weight is increasing. What change should you make in his therapy? (A) Eat a bedtime snack (B) Decrease his insulin glargine dose (C) Decrease his insulin glargine dose and increase his dinner insulin lispro dose (D) Decrease his insulin glargine dose and add repaglinide with dinner (E) Add an amylin analog, like pramlintide

Answer 41

C (A) is incorrect. His bedtime levels are already high (and he is gaining weight) so he shouldn’t eat more at bedtime. (B) will not correct his bedtime hyperglycemia. (C) will normalize his fasting and bedtime glucose levels, obviating his need for a large breakfast. (D) is incorrect...there is no reason to add an oral insulin secretatogue when the patient is already taking rapidly acting insulin with meals. Pramlintide (E) will increase his risk of hypoglycemia.

Question 42

``` An 18 year-old thin college student comes to the emergency room with nausea, vomiting, extremely high blood glucose values (>800 mg/dl), dehydration and ketoacidosis. She is admitted for treatment with intravenous fluids and intravenous insulin. The insulin ordered is: Answer: (C) Discussion: (A) NPH insulin (B) Insulin glargine (C) Regular insulin (D) Insulin aspart (E) Insulin lispro ```

Answer 42

C | Only regular insulin should be given IV

Question 43

``` A 53 year-old obese inactive man has newly diagnosed type 2 diabetes. He attended diabetes education classes and met with a dietitian. Glucose levels are still elevated. Which one of the following treatments should not be used? (A) Metformin alone (B) Glyburide alone (C) Metformin plus glyburide (D) Metformin plus repaglinide (E) Repaglinide plus glyburide ```

Answer 43

E | Both agents are insulin secretagogues and so are not used together

Question 44

``` Which one of the following is the best indicator to follow the effectiveness of treatment for diabetic ketoacidosis? (A) Decrease in ketones (B) Increase in ketones (C) Decrease in anion gap (D) Increase in anion gap (E) Decrease in blood glucose levels. ```

Answer 44

C Decrease in anion gap. The anion gap should decrease with fluid and insulin treatment of diabetic ketoacidosis. If the anion gap does not decrease then the insulin infusion rate should be increased. Ketones can increase or decrease with effective treatment depending on the redox state of the patient because acetoacetate but not ß-hydroxybutyrate is measured. As the redox state or oxygenation of the patient improves, ß-hydroxybutyrate is converted to acetoacetate leading to an increase in measured ketones despite patient improvement. Glucose should decrease with treatment; however, glucose may start at relatively low levels (250-300 mg/dl) and normalize more quickly than acid base changes.

Question 45

``` Counterregulatory hormones are released during stress. An increase in these hormones can result in insulin deficiency, and potentially, diabetic ketoacidosis. Which one of the following is not a counterregulatory hormone? (A) Glucagon (B) Epinephrine (C) Cortisol (D) Aldosterone (E) Growth hormone ```

Answer 45

D Glucagon increases gluconeogenesis and ketogenesis in the liver Epinephrine increases gluconeogenesis in the liver, decreases insulin secretion from the pancreatic beta cell, and decreases glucose uptake in muscle. Cortisol increases gluconeogenesis and decreases peripheral glucose uptake. Growth hormone increases insulin resistance and decreases glucose uptake in muscle. Aldosterone is not a counter regulatory hormone released during stress.

Question 46

A patient in diabetic ketoacidosis (DKA) is admitted with a potassium of 7 mEq/L (normal 3.5-5 mEq/L). Which one of the following statements is true? (A) The potassium will remain high with treatment of the DKA (B) Because of the DKA, the patient has an excess of total body potassium (C) The patient’s acidemia is one of the causes for the patient’s elevated potassium (D) Treating the patient with insulin will raise the potassium level

Answer 46

C The patient’s acidemia is one of the causes for the patient’s elevated potassium (C). Acidemia causes an elevation of potassium levels because of extracellular to intracellular ion exchange. With treatment of DKA, potassium levels fall because of reversal of the acidemia, insulinopenia and dilutional effects of the fluids. There is total body potassium deficit unless the patient has renal failure. Treatment with intravenous potassium in patients with concomitant renal failure should be done carefully.

Question 47

All of the following would be consistent with laboratory values measured in a patient with diabetic ketoacidosis (DKA) except: (A) Hyperglycemia (B) Hyperkalemia (C) Insulin deficiency (D) Volume excess (E) Mixed anion gap and hyperchloremic metabolic acidosis

Answer 47

``` D Volume excesss (D). Patients with DKA have a significant volume deficit of 7-12L of fluid; all of the other values may be found in a patient with DKA. ```

Question 48

``` You admit two patients to the hospital. One patient has DKA (diabetic ketoacidosis) and the other has HHS (hyperosmolar hyperglycemic state). Which statement would best describe the patient with HHS? (A) Higher serum glucose (B) Greater acidemia (C) Lower bicarbonate (D) Higher ketones (E) Type 1 diabetes mellitus ```

Answer 48

A Higher serum glucose (A). Patients with HHS generally have type 2 diabetes and will generally present with a higher serum glucose and osmolality. Patients with DKA are acidotic with elevated ketones, and decreased bicarbonate and an associated decreased pH. Because of symptoms associated with the acidemia, i.e. vomiting, abdominal pain, etc, they may present early with only sightly elevated glucose levels.

Question 49

A patient is admitted with severe DKA with a pH of 6.9 and serum bicarbonate of less than 5. The patient’s serum potassium is 8 (normal 3.5-5.0 mmol/L). Which one of the following statements is not correct? A) Insulin stimulates potassium uptake into cells B) The patient’s total body potassium is elevated C) The patient’s serum potassium will likely drop with treatment D) Treatment with IV potassium should not be started immediately E) Reversal of acidemia associated with DKA leads to movement of potassium into cells

Answer 49

B The patient’s total body potassium is elevated. Acidemia and hypoinsulinemia cause a decrease in cellular potassium and an increase in serum potassium. The increased serum potassium is lost with the osmotic diuresis, which leads to total body depletion. Replacement is started once renal failure is ruled out and the potassium drops with treatment.

Question 50

Patients with type 1 or type 2 diabetes decompensate and develop DKA or HHS (hyperosmolar hyperglycemic state) because they 1) have a relative insulin deficiency; 2) have increased counterregulatory hormones (glucagon, catecholamines, cortisol and growth hormone); and 3) are volume depleted. Which one of the following statements are correct except: (A) Counterregulatory hormones are elevated when a patient is stressed (B) An increase in counterregulatory hormones decreases the effective insulin concentration (C) IV fluid is critical in the treatment of both DKA and HHNK (D) A diabetic who is vomiting and not eating should stop taking insulin (E) A diabetic who gets pneumonia may need to increase their insulin dose

Answer 50

D A stressed patient who is vomiting from a primary illness or from the acidosis associated with DKA will likely need more insulin despite not eating because the stress increases glucose release from the liver due to counterregulatory anti-insulin hormones.

Question 51

An elderly nursing home resident with a history of stroke and type 2 diabetes mellitus is brought to the emergency department in a coma. Each of the following is consistent with HHS (hyperosmolar, hyperglycemic state) except: A. Elevated BUN and creatinine B. Hyperglycemia C. Hypernatremia D. Hyperosmolality E. Volume excess

Answer 51

E | Patients w/ HHS have a fluid deficit b/c of osmotic diuresis

Question 52

``` A patient is admitted to the hospital in diabetic ketoacidosis (DKA). She is given fluids, and insulin bolus intravenously and then started on an insulin drip. Which one of the following best measures the effectiveness of DKA treatment? A. Anion gap B. Epinephrine levels C. Serum glucose levels D. Serum ketones E. Serum sodium levels ```

Answer 52

A Following the anion gap is the best way to follow the treatment of a patient with DKA. Ketones can paradoxically increase as the redox state changes with treatment. Epinephrine levels are not measured in DKA. Glucose decreases with treatment but it decreases faster than ketoacidosis. Measured serum sodium levels are typically normal in DKA.