1.

What is the most common cause

of hypothyroidism
worldwide?
A. Autoimmune disease
B. Graves disease
C. Iatrogenic causes
D. Iodine deficiency
E. Medication side effects
2.

A 23-year-old woman presents to

clinic complaining
of months of weight gain, fatigue,
amenorrhea, and worsening
acne. She cannot identify when her
symptoms began
precisely, but she reports that without a
change in her
diet she has noted a 12.3-kg weight gain
over the past 6
months. She has been amenorrheic for
several months.
On examination she is noted to have
truncal obesity with
bilateral purplish striae across both flanks.
Cushings syndrome
is suspected. Which of the following tests
should
be used to make the diagnosis?
A. 24-h urine free cortisol
B. Basal adrenocorticotropic hormone
(ACTH)
C. Corticotropin-releasing hormone (CRH)
level at 8 A.M.
D. Inferior petrosal venous sampling
E. Overnight 1 mg dexamethasone
suppression test
3. Secretion of gonadotropin
releasing-hormone (GnRH)
normally stimulates release of luteinizing
hormone (LH)
and follicle-stimulating hormone (FSH)
which promote
production and release of testosterone
and estrogen.
Which mechanism below best explains
how long-acting
gonadotropin-releasing hormone agonists
(e.g., leuprolide)
decrease testosterone levels in the
management of
prostate cancer?
A. GnRH agonists also promote production
of sex hormone

binding globulin, which decreases the

availability
of testosterone
B. Negative feedback loop between GnRH
and LH/FSH
C. Sensitivity of LH and FSH to pulse
frequency of GnRH
D. Translocation of the cytoplasmic
nuclear receptor
into the nucleus with constitutive
activation of
GnRH
4. A 44-year-old woman seeks
evaluation for irregular
menstrual cycles with heavy menstrual
bleeding. She reports
that her menses had been regular with 28day cycles
since her early twenties. However, for the
past 6 months,
her cycles have been 2225 days with
heavy associated
bleeding that is unusual for her. She has
had rare hot
flashes and sleep disturbance. She is
requesting assistance
in controlling these symptoms. You
suspect she is perimenopausal,
and hormonal testing on day 2 of her
menses confirms this suspicion. You are
considering
treatment with oral contraceptives for
control of her
symptoms and to protect against
unintended pregnancy.
All of the following would be considered
contraindications
to use of oral contraceptive pills except
A. breast cancer
B. cigarette smoking
C. kidney disease
D. liver disease
E. prior history of deep venous thrombosis
5.

All the following are risk factors for

the development
of osteoporotic fractures except
A. African-American race
B. current cigarette smoking
C. female sex
D. low body weight
E. physical inactivity

6.

All the following drugs are

associated with an increased
risk of osteoporosis in adults except
A. cyclosporine
B. dilantin
C. heparin
D. prednisone
E. ranitidine
7. A 34-year-old woman presents to
your clinic with a variety
of complaints that have been worsening
over the past
year or so. She notes fatigue, amenorrhea,
and weight
gain. She states that her primary
physician diagnosed her with
hypothyroidism several months ago, and
she has
been faithfully taking thyroid hormone
replacement. Her
thyroid-stimulating hormone (TSH) has
been in the normal
range over the last two laboratory checks.
When her
symptoms did not improve on synthroid,
she was sent
to your clinic for further evaluation. A
diagnosis of panhypopituitarism
is considered. All of the following are
consistent with normal pituitary function
except
A. basal elevation of follicle-stimulating
hormone
(FSH) and luteinizing hormone (LH) in a
postmenopausal
woman
B. elevation of aldosterone after infusion
of cosyntropin
C. elevation of growth hormone after
ingestion of a
glucose load
D. elevation of cortisol after injection of
regular insulin
E. elevation of TSH after infusion of
thyrotropinreleasing
hormone (TRH)
8.

A 33-year-old male with end-stage

renal disease who is
on hemodialysis complains of decreased
libido, inability
to maintain erections, increasing fatigue,
and mild weakness.

He has been on a stable hemodialysis

regimen for 8
years, and all his electrolytes are normal.
Further evaluation
reveals a reduced serum testosterone
level. Measurement
of which of the following will distinguish
primary
from secondary hypogonadism?
A. Aldosterone
B. Cortisol
C. Estradiol
D. Luteinizing hormone
E. Thyroid-stimulating hormone
9. A 42-year-old woman is brought to
the emergency
room by ambulance for altered mental
status. The glucose
level by fingerstick monitoring was below
the measurement
capabilities of the monitor (<40 mg/dL).
After
2 ampules of 50% dextrose, the patients
fingerstick glucose
remains at 42 mg/dL. She remains
unconscious and
had a 1-min seizure while in transport. She
has no history
of diabetes mellitus. Her family denies
that she has been
recently ill, but recently she has been
depressed. She
works as a registered nurse on a medical
floor of the hospital.
Which of the following tests would confirm
an
overdose of exogenous insulin?
A. Plasma glucose <55 mg/dL, plasma
insulin >18
pmol/L, and plasma C-peptide levels
undetectable
B. Plasma glucose <55 mg/dL, plasma
insulin >18
pmol/L, and plasma C-peptide levels >0.6
ng/mL
C. Plasma glucose <55 mg/dL, plasma
insulin <18
pmol/L, and plasma glucagon <12 pmol/L
D. Plasma glucose <55 mg/dL, plasma
insulin <18
pmol/L, and C-peptide levels undetectable
10. A 44-year-old male is involved in a
motor vehicle collision.

He sustains multiple injuries to the face,

chest, and
pelvis. He is unresponsive in the field and
is intubated for
airway protection. An intravenous line is
placed. The patient
is admitted to the intensive care unit (ICU)
with
multiple orthopedic injuries. He is
stabilized medically
and on hospital day 2 undergoes
successful open reduction
and internal fixation of the right femur and
right humerus.
After his return to the ICU, you review his
laboratory values. TSH is 0.3 mU/L, and
the total T4 level
is normal. T3 is 0.6 g/dL. What is the most
appropriate
next management step?
A. Initiation of levothyroxine
B. A radioiodine uptake scan
C. A thyroid ultrasound
D. Observation
E. Initiation of prednisone
11. All the following biochemical
markers are a measure
of bone resorption except
A. serum alkaline phosphatase
B. serum cross-linked N-telopeptide
C. serum cross-linked C-telopeptide
D. urine hydroxyproline
E. urine total free deoxypyridinoline
12.A 54-year-old woman is referred to
endocrinology
for evaluation of osteoporosis after a
recent evaluation of
back pain revealed a compression fracture
of the T4 vertebral
body. She is perimenopausal with irregular
menstrual
periods and frequent hot flashes. She does
not
smoke. She otherwise is well and healthy.
Her weight is 70
kg, and height is 168 cm. A bone mineral
density scan
shows a T-score of 3.5 SD and a Z-score
of 2.5 SD. All
of the following tests are indicated for the
evaluation of
osteoporosis in this patient except
A. 24-h urine calcium

B. follicle-stimulating hormone and

luteinizing hormone
levels
C. serum calcium
D. renal function panel
E. vitamin D levels (25-hydroxyvitamin D)
13. A 67-year-old woman presents to
clinic after a fall
on the ice a week ago. She visited the
local emergency
room immediately after the fall, where hip
radiographs
were performed and were negative for
fracture or dislocation.
They did reveal fusion of the sacroiliac
joints and
coarse trabeculations in the ilium,
consistent with Paget
disease. A comprehensive metabolic panel
was also sent
at that visit and is remarkable for an
alkaline phosphatase
of 157 U/L, with normal serum calcium and
phosphate
levels. She was discharged with analgesics
and told
to follow up with her primary care doctor
for further
management of her radiographic findings.
She is recovering
from her fall and denies any long-standing
pain or
immobility of her hip joints. She states
that her father and hearing loss near the
end of his life. She is very concerned
about the radiographs and wants to know
what
they mean. Which of the following is the
best treatment
strategy at this point?
A. Initiate physical therapy and non-weight
bearing exercises
to strengthen the hip.
B. No treatment; she is asymptomatic.
Follow radiographs
and laboratory findings every 6 months.
C. Prescribe vitamin D and calcium.
D. Start an oral bisphosphonate.
E. Start high-dose prednisone with rapid
taper over 1
week.

14. A 26-year-old woman presents

with 2 weeks of nausea,
vomiting, and jaundice. She has been
previously
healthy and has no past medical history.
On examination,
a palpable liver edge is appreciated.
Ocular findings are
presented in Figure X-14 (Color Atlas). Her
transaminases
and total bilirubin are elevated. Which of
the following
tests will lead to a definitive diagnosis in
this patient?
A. Anti-smooth-muscle antibody
B. Hepatitis B surface antigen
C. Liver biopsy with quantitative copper
assay
D. Serum ceruloplasmin
E. Total iron-binding capacity and ferritin
15. A 29-year-old woman presents to
your clinic complaining
of difficulty swallowing, sore throat, and
tender
swelling in her neck. She has also noted
fevers intermittently
over the past week. Several weeks prior to
her current
symptoms she experienced symptoms of
an upper
respiratory tract infection. She has no past
medical history.
On physical examination, she is noted to
have a
small goiter that is painful to the touch.
Her oropharynx
is clear. Laboratory studies are sent, and
reveal a white
blood cell count of 14,100 cells/ L with a
normal differential,
erythrocyte sedimentation rate (ESR) of 53
mm/h,
and a thyroid-stimulating hormone (TSH)
of 21
U/mL.
Thyroid antibodies are negative. What is
the most likely
diagnosis?
A. Autoimmune hypothyroidism
B. Cat-scratch fever
C. Graves disease
D. Ludwigs angina
E. Subacute thyroiditis

16. What is the most appropriate

treatment for the patient
described above?
A. Iodine ablation of the thyroid
B. Large doses of aspirin
C. Local radiation therapy
D. No treatment necessary
E. Propylthiouracil
17.The Diabetes Control and
Complications Trial (DCCT)
provided definitive proof that reduction in
chronic hyperglycemia
A. improves microvascular complications
in type 1 diabetes
mellitus
B. improves macrovascular complications
in type 1 diabetes
mellitus
C. improves microvascular complications
in type 2 diabetes
mellitus
D. improves macrovascular complications
in type 2 diabetes
mellitus
E. improves both microvascular and
macrovascular
complications in type 2 diabetes mellitus
18. A 54-year-old woman undergoes
thyroidectomy for
follicular carcinoma of the thyroid. About 6
h after surgery,
the patient complains of tingling around
her mouth.
She subsequently develops a pins-andneedles sensation
in the fingers and toes. The nurse calls the
physician to
the bedside to evaluate the patient after
she has severe
hand cramps when her blood pressure is
taken. Upon
evaluation, the patient is still complaining
of intermittent
cramping of her hands. Since surgery, she
has received
morphine sulfate, 2 mg, for pain and
compazine, 5 mg,
for nausea. She has had no change in her
vital signs and is
afebrile. Tapping on the inferior portion of
the zygomatic
arch 2 cm anterior to the ear produces
twitching at the

corner of the mouth. An electrocardiogram

(ECG) shows
a QT interval of 575 ms. What is the next
step in evaluation
and treatment of this patient?
A. Administration of benztropine, 2 mg IV
B. Administration of calcium gluconate, 2
g IV
C. Administration of magnesium sulphate,
4 g IV
D. Measurement of calcium, magnesium,
phosphate,
and potassium levels
E. Measurement of forced vital capacity
19.A 49-year-old male is brought to
the hospital by his
family because of confusion and
dehydration. The family
reports that for the last 3 weeks he has
had persistent
copious watery diarrhea that has not
abated with the use
of over-the-counter medications. The
diarrhea has been
unrelated to food intake and has persisted
during fasting.
The stool does not appear fatty and is not
malodorous.
The patient works as an attorney, is a
vegetarian,
and has not traveled recently. No one in
the household
has had similar symptoms. Before the
onset of diarrhea,
he had mild anorexia and a 5-lb weight
loss. Since the
diarrhea began, he has lost at least 10
pounds. The physical
examination is notable for blood pressure
of 100/70,
heart rate of 110/min, and temperature of
36.8C
(98.2F). Other than poor skin turgor,
confusion, and
diffuse muscle weakness, the physical
examination is
unremarkable. Laboratory studies are
notable for a normal
complete blood count and the following
chemistry
results: