Wild Brilliance Questions Flashcards
Which of the following amino acids is most important for proper thyroid function?
a. L-lysine
b. L-tyrosine
c. L-tryptophan
d. L-leucine
L-tyrosine
L-tyrosine is the precursor for thyroid hormone synthesis.
In order to differentially diagnose autoimmune hypothyroidism, which of the following tests would you order?
a. Antithyroglobulin and antiendomesial antibodies
b. Antimyoglobin and antithyroglobulin antibodies
c. Antimicrosomal and antithyroglobulin antibodies
d. Antithyroglobulin and antinuclear antibodies
Antimicrosomal and antithyroglobulin antibodies
Antimicrosomal and antithyroglobulin antibodies are diagnostic for autoimmune hypothyroidism, in the presence of elevated TSH.
Microsomes are found inside thyroid cells. The body produces antibodies to microsomes when there has been damage to thyroid cells. The antithyroid microsomal antibody test measures these antibodies in the blood.
Based on her current hypothyroidism symptoms, you would expect her labs to reveal?
a. Elevated free T3
b. Decreased TSH
c. Elevated TSH
d. Elevated total T4
Elevated TSH
Explanation: This patient has symptoms of hypothyroidism, which probably is autoimmune in etiology. Her symptoms of insomnia, anxiety, and elevated heart rate preceding the fatigue and weight gain point to autoimmune (Hashimoto) thyroiditis. At this stage in her case, with symptoms of hypothyroidism, her TSH will be elevated, and her T3 and T4 will most likely be reduced.
During her visit with you, your patient begins to become emotional while talking about her fatigue, saying that she feels overwhelmed and depressed sometimes. She starts crying and reaches for a tissue. Which of the following responses would be best?
a. Say to her, ‘Your depression is probably just because of the hypothyroidism. I wouldn’t worry about it.’
b. Say to her, I can tell this is difficult for you, and wait in silence until she is ready to continue speaking.
c. Keep your eyes on your medical notes because making eye contact can make her even more uncomfortable.
d. Make her feel more at ease by changing the subject and discussing another aspect of her medical history.
Say to her, I can tell this is difficult for you, and wait in silence until she is ready to continue speaking.
Explanation: When patients are having difficulty emotionally with a certain subject during the medical intake, it is usually best to simply acknowledge the fact that it is an emotional subject, and to listen to them speak, or let them cry if they need to. Most of the time, it is best not to try to fix the problem right away, or to change the subject. Please do not dismiss what your patients tell you, as in option D; this can create an impression of disrespect, and it can also potentially set you up to miss a diagnosis.
Which of the following statements is true regarding thyroid hormone medications?
a. Synthetic T3 is used more often than synthetic T4 in thyroid medications because it has a longer half life in the body.
b. The synthetic active ingredient in triiodothyronine is chemically identical to the natural hormone TSH.
c. The synthetic active ingredient in levothyroxine is chemically identical to the hormone T4.
d. Dessicated thyroid medication contains only T3, which is synthesized into biologically active T4 in the cells.
The synthetic active ingredient in levothyroxine is chemically identical to the hormone T4.
Explanation: The active ingredient in levothyroxine (Synthroid) is chemically identical to T4. There are fillers, additives, and colors in the tablet, but the active ingredient is exactly the same as T4.
Dessicated thyroid (Armour Thyroid) medication contains both T3 and T4. Synthetic T4 is used far more frequently than T3, because the half-life of T4 is significantly longer. T4 is converted into the more physiologically active T3 by deiodination in the periphery.
Which of the following herbs can affect the thyroid gland to reduce the symptoms of hyperthyroidism?
a. Melissa officinalis
b. Larrea tridentata
c. Calendula officinalis
d. Medicago sativa
Melissa officinalis
Explanation: Melissa officinalis may be prescribed for hyperthyroidism, in conjunction with Lycopus, Leonurus, and Lithospermum. These herbs are not likely to affect thyroid function in people without hyperthyroidism.
Remember the 3 L’s for Thyroid!
What is the most appropriate treatment given the likely diagnosis?
a. Prescription of spironolactone
b. Surgical removal of likely pituitary mass
c. Recommending intramuscular vitamin B12 injections
d. Administration of Hypericum perforatum tincture
Surgical removal of likely pituitary mass
Explanation: Given the totality of the evidence in the case, it is most likely he has a pituitary mass that needs to be surgically removed.
Medical therapy may also be necessary, using cortisol synthesis inhibitors like ketoconazole, mitotane, or methyrapone.
Spironolactone is not appropriate in this case, it is used to treat hyperaldosteronism.
Hypericum has no place here, nor do vitamin B12 injections.
What does the impaired left lateral eye abduction indicate?
a. A lesion of the left cerebral cortex
b. A lesion of the left retinal artery
c. A lesion of the left abducens nerve
d. A lesion of the left trigeminal nerve
Abducens nerve lesions typically impair abduction of the eyeball.
Lesions of the trigeminal nerve would affect the masseter or temporal muscles on that side, and are very often associated with painful trigeminal neuralgia.
Cerebral cortex lesions typically cause problems ranging from hemiparesis to problems speaking, facial deviation, hearing loss, abnormal movements, and many other problems depending on which lobe is affecting, nothing like what this patient is experiencing.
And a retinal artery lesion sufficient to cause many of his problems would be visible on fundoscopy in most cases. This problem is likely due to increased intracranial pressure from a mass impinging the left ocular nerve.
He has significant facial swelling, a mild buffalo hump, truncal obesity, and bilateral non-tender gynecomastia. Optic exam reveals decreased left pupillary light response, defective left lateral eye abduction, and impaired lower field defects in the left eye. Fundoscopic exam was normal. The most likely diagnosis is ____________.
a. Adrenal Cushing’s disease
b. Pituitary Addison’s disease
c. Pituitary Cushing’s disease
d. Adrenal Addison’s disease
Pituitary Cushing’s disease
Explanation: The combination of weight gain (in the pattern of centripetal obesity and buffalo hump), uncontrollable hypertension, moon facies, and easy bruising (secondary to skin thinning, thus exposing the capillaries to more trauma) are all strong signs he has Cushing’s disease.
The signs pointing to a mass impinging the optic nerve easily fits with it being a pituitary macroadenoma that is hypersecreting ACTH. This occurs in only about 10% of patients with Cushing’s disease, with the vast majority of the rest being due to iatrogenic steroid use or adrenal lesions.
Addison’s disease more typically causes weight loss, abdominal pain, weakness, and darkening of the skin.
Which imaging study is indicated and why?
a. CT; to rule out degeneration of the optic chiasm
b. US; to rule out swelling in the ventricles of the brain
c. No imaging is indicated
d. MRI; to rule out a mass impinging on the L ocular nerve
MRI; to rule out a mass impinging on the L ocular nerve
Explanation: Almost all of the signs on the ocular exam point to a lesion impinging on the left ocular nerve. It could be a retinal problem, but with normal fundoscopy that is extremely unlikely.
MRI is the best and safest imaging to assess if this is correct.
In office, the child reports feeling tired and you notice that he is slumped forward. His mother reports that she has a hard time getting him to drink water, which she has been working on since she thought he was getting sick. She also notes that he does not do well with bad news and often will have an upset stomach and loose stools. Based on these observations and his presentation, what which homeopathic remedy would be most beneficial?
a. Belladonna
b. Cina
c. Chamomile
d. Gelsemium
d. Gelsemium
Explanation: Gelsemium is the most correct answer based on his primary symptoms of being sluggish, weak, and tired. Gelsemium is also thirstless and is worse from fright and bad news, often resulting in diarrhea. Belladonna is also thirstless, but the rest of the picture does not fit the patient. Cina and chamomile are common children’s remedies but do not fit this patient’s case.
Patient presents with his mother for fatigue. His mother reports that he appears more sluggish and weaker than usual. She is concerned that he is not participating in activities that he usually enjoys. This occurred abruptly approximately two weeks ago. His mother initially thought he was developing an infection but became worried when his symptoms worsened. He has been having difficulty sleeping at night, stating that his back has been hurting. She has additionally noticed increased bruising, which she initially attributed to rough play.
PHYSICAL EXAMINATION: Oral temperature: 101.6 deg F (38.7 deg C). HEENT exam reveals gum pallor, all other findings were within normal limits. Lymph exam negative for lymphadenopathy. Lungs clear to auscultation. Heart auscultation reveals regular rate and rhythm. Abdominal exam reveals hepatosplenomegaly
- You are suspicious of malignancy. Based on the information given, what is the most likely diagnosis?
a. Non-Hodgkin’s Lymphoma
b. Chronic lymphocytic leukemia
c. Acute lymphoblastic leukemia
d. Acute myelogenous leukemia
- Based on your working diagnosis, what lab testing do you need to diagnose the patient?
a. A complete metabolic panel and serum CRP
b. A lumbar puncture
c. A complete blood count with a differential and peripheral smear
d. A bone marrow aspirate and biopsy
- Acute lymphoblastic leukemia
Explanation: ALL is the most likely diagnosis based on the presentation and age of the patient. ALL typically occurs in patients aged 2-9 and is characterized by acute development of fatigue, fever, anemia, bone pain, and hepatosplenomegaly. Lymphadenopathy may also be present although it was absent in this patient. CLL is most common in elderly patients and often is asymptomatic, except for hypercoagulability. The lack of non-tender lymphadenopathy decreases the likelihood of Non-Hodgkin’s Lymphoma. Although AML shares many symptoms with AML, it most typically occurs in patients over 65.
- bone marrow aspirate and biopsy
Explanation: ALL is diagnosed with a bone marrow aspirate and biopsy. However, a complete blood count with a differential and peripheral smear is often the first step if you are suspicious of ALL. A lumbar puncture may be used to detect central nervous involvement in patients who have ALL.
In addition to a referral to an oncologist, you decide to recommend the following nutritional supplementation to improve sleep:
a. Magnesium glycinate 150mg an hour before bed
b. Phosphatidylcholine 200 mg twice per day
c. Molybdenum 60 mcg three times per day
d. Carnitine 300 mg after dinner
Magnesium glycinate 150mg an hour before bed
Explanation: Magnesium is the best option to promote sleep in this child, especially as magnesium is often depleted in patients with Leukemia.
Carnitine and phosphatidylcholine are primarily used for improving cognition, but not for sleep.
The dose of molybdenum is too high for a child and is not indicated for sleep.
PATIENT:
43-year-old white woman, 5’8”; (172.7 cm), 145 lbs (65.8 kg)
PRESENTATION:
She presents to your clinic with a chief complaint of periodic wheezing, coughing, shortness of breath, and chest discomfort. She reports these symptoms occur less than twice a week and occasionally at night. She did not have any of these symptoms before she moved into a remodeled home six months ago.
Which of the following is most likely to be considered in your differential diagnosis?
a. Heart failure
b. Asthma
c. Panic disorder
d. Carcinoid syndrome
Which of the following findings would support one of the diagnoses in your differential?
a. A reduced residual volume (RV)
b. Normal chest x-ray
c. Eosinophilia
d. Increased FEV1
A week later, the patient returns to your office with respiratory distress, tachypnea, and tachycardia. Auscultation of the lungs reveals a prolonged expiratory phase with high-pitched wheezes during inspiration and most of expiration. There are coarse rhonchi in addition to the wheezes but no fine crackles. The patient is having difficulty saying more than a few words at a time. Which of the following is the most appropriate next step?
a. Give the patient deferoxamine IM and have her return in 24 hours for assessment.
b. Administer inhaled albuterol if available or call for transport to the emergency room.
c. Begin administering intravenous dexamethasone in the office.
d. Prescribe fluticasone and have the patient return in two weeks.
Assuming she has mild, intermittent disease, which of the following is indicated?
a. High-dose inhaled corticosteroids
b. Inhaled corticosteroids in a medium-dose range with a leukotriene modifier or theophylline
c. Low-dose inhaled corticosteroids and theophylline
d. No daily medication needed.
What helpful nutritional recommendations would you make for this patient that may be for her condition?
a. Reduce vitamin C intake.
b. Eat plenty of salt in the diet.
c. Increase vitamin K intake.
d. Remove any processed foods and preservatives from the diet.
- Asthma
Explanation: In a woman of her age with these symptoms, asthma is the most likely diagnosis. It is most likely allergic asthma, and possibly aggravated by exposure to chemicals in her apartment that was recently remodeled - Eosinophilia
Explanation: Asthma is often associated with elevations in eosinophil count. There is also usually decreased FEV1, increased residual lung volume, and hyperinflated lungs on chest x-ray. - Administer inhaled albuterol if available or call for transport to the emergency room.
Explanation: She should have had a short-acting beta-agonist (SABA) inhaler already prescribed to her at her first visit, and patient education must be given regarding prevention and treatment of acute attacks. If she does not have a rescue inhaler and one is not available, emergency medical transport would be necessary to prevent worsening of this asthma attack. Corticosteroids are administered at the emergency department for acute asthma attacks, where support for respiratory arrest is available; she would need a bronchodilator in an outpatient setting. - No daily medication needed.
Explanation: There is no need for daily suppressive medication for people with mild, intermittent asthma. These patients should have a rescue inhaler on hand in case of severe sudden symptoms. Naturopathic treatments often lead to complete symptom resolution over time if simple cases like this are managed properly. - Remove any processed foods and preservatives from the diet.
Explanation: Processed food increases risk of inflammation, which tends to exacerbate asthma and allergies.
PATIENT: 71-year-old African-American male, 5’ 10” (178 cm), 170 lbs (77 kg)
PRESENTATION: He presents with a complaint of constant aching in his back. The aching has progressively worsened over the course of the last six months. His spouse, who accompanies him on his visit, tells you that he sleeps much of the day.
PHYSICAL EXAMINATION: Upon examination, you note that the patient’s spine is tender to palpation. All other physical exam findings are normal, including lymph nodes, liver, and spleen.
PRELIMINARY LAB RESULTS: You order blood tests that reveal a mild anemia with a low serum hemoglobin level and low MCV. Platelets and white blood cells are normal. Rouleaux are noted on his blood smear. Radiographs of the spine show osteoporosis and compression fractures of the third and fourth lumbar vertebrae.
- What laboratory finding would support your suspected diagnosis?
a. Elevated red blood cell levels
b. M-spike on serum protein electrophoresis
c. Low erythropoietin levels
d. Elevated hematocrit, decreased hemoglobin
2. Which of the following is most likely cause of his symptoms?
a. Macroglobulinemia
b. Multiple myeloma
c. Avascular necrosis
d. Polycythemia vera
3. What further lab testing or imaging would be LEAST helpful in establishing a specific diagnosis?
a. Fecal leukocyte analysis
b. MRI scan of the spine
c. Bone marrow biopsy
d. Serum protein electrophoresis
- M-spike on serum protein electrophoresis
Explanation: In cases of multiple myeloma, there there will be elevated monoclonal antibodies (an M-spike) on serum protein electrophoresis. - Multiple myeloma
Explanation: Multiple myeloma often presents with back pain, anemia, weight loss, and fatigue. - What further lab testing or imaging would be LEAST helpful in establishing a specific diagnosis?
a. Fecal leukocyte analysis
Explanation: A bone marrow biopsy with serum protein electrophoresis is diagnostic for multiple myeloma. An MRI would be needed prior to a biopsy for determining the exact location and extent of the mass. Urine testing is standard for multiple myeloma, but stool testing is not appropriate workup in this condition.
