USMLE STep 3 Question #486

A 56-year-old male with Type II diabetes presents to you today for a follow-up visit. Three months prior his A1c was 8.9% and he was started on metformin. Today his A1c is 7.4%. He is significantly overweight with a BMI of 33. You would like to initiate another medication for glucose control, specifically one that does not carry a risk of weight gain. Which of the following drugs is weight neutral?

  • A.  Glimepride
  • B. Rosiglitazone
  • C.  Pioglitazone
  • D. Sitagliptin
  • E. Glyburide

Question of the Week # 421

421) A 34-year-old woman with history of oligomenorrhea presents to your clinic to discuss her results of recent work-up. One week ago, she has undergone extensive work-up for her menstrual abnormality. A serum pregnancy test is negative. Thyroid stimulating hormone, serum prolactin  level and Follicle Stimulating Hormone levels are within normal limits. Serum total testosterone is 120ng/dl ( N = 30 to 90ng/dl) and serum free testosterone is 0.9 ng/dl ( N= 0.4 to 0.8 ng/dl) . A dehydro-epiandrosterone level is 400 mcg/dl (45- 270 ug/dL) . A pelvic ultrasound reveals multiple cysts in the ovaries bilaterally. On examination, she is obese with a BMI of 32. She has excess thick and pigmented hair above her upper lip and on the chin. Which of the following is indicated in this patient at this time?

A) Fasting Plasma Glucose

B) Random Blood Glucose

C) Hemoglobin A1C

D) Oral Glucose Tolerance Test

E) Start Metformin

Question of the Week # 420

420) A 34-year-old woman with past medical history of Hypothyroidism presents to the outpatient clinic for follow-up visit. She delivered a health male baby about one week ago and has been breast feeding without any issues. She has no complaints. During the pregnancy she required increase of her levothyroxine dose to 0.175 mcg from  her usual pre-pregnancy dose of 0.125mcg. Her TSH level about 2 weeks ago was 2.0µu/ml. She denies any cold or heat intolerance, weakness or constipation. On physical examination, vitals are stable. There is no goiter. Deep tendon reflexes are normal.  Which of the following is the most appropriate management at this time?

A) Decrease Levothyroxine to pre-pregnancy dose and recheck TSH in 6 weeks

B) Repeat TSH in 6 weeks before dose adjustment

C) Increase Levothyroxine and repeat TSH in 6 weeks

D) Repeat TSH now

E) Obatin Thyroid Peroxidase antibodies

Question of the Week # 419

419) A 26-year-old woman presents for an ante-natal check up after her home pregnancy test showed positive result. Her last menstrual period was 5 weeks ago. Her past medical history includes hypothyroidism for which she has been using 125 mcg of levo-thyroxine for the past five years. She did not require any dose adjustment of her thyroid hormone therapy in the past 4 years. Her most recent thyroid stimulating hormone level ( TSH) was performed 2 weeks ago and was 2.5µU/ml ( N = 0.5 to 5.0 µU/ml). She denies any cold intolerance, weakness or constipation. She has gained about 2 lbs weight in the past one month. On physical examination, vitals are stable. There is no goiter. Reflexes are 1+ in bilateral lower extremities and there is 1+ pre-tibial edema. Laboratory investigations reveal :

Thyroid Stimulating Hormone :  2.5 µU/ml( N = 0.5 to 5.0 µU/ml)

Serum Total T4: 13.9 µg/dl ( N = 5 to 12µg/dl)

Serum Free T4 :  1.9 ng/dl ( N = 0.9 to 2.4ng/dl)

Which of the following is the most recommendation?

A) Decrease Levothyroxine and recheck TSH in 4 weeks

B) Continue same dose Levothyroxine and repeat TSH in 4 weeks

C) Increase Levothyroxine and repeat TSH in 4 weeks

D) Repeat TSH in 8 to 10 weeks

E) Check Serum thyroid binding globulin levels

Question of the Week # 390

390)  A 28 year old woman has had amenorrhea for the past 4 months. She reports having regular menstrual cycles prior to these episodes. She is sexually active and a home pregnancy test was negative on two occasions over the last one week. She denies any excessive stress or physical activity. She has had headaches almost daily over the past three months. She denies any visual deficits. Her past medical history is significant for schizophrenia for which she is using risperdal for several years with good control of her disease. On examination, her vitals are stable. Body mass index is about 28 . There is milky discharge on breast examination. Pelvic exam is normal. Serum pregnancy test is negative. A serum prolactin level is 30mcg/ml (5 to 20 mcg/L). A serum Thyroid Stimulating Hormone and Follicle Stimulating Hormone level are within normal limit. An MRI of the brain reveals 10 cm lobulated mass in the anterior skull base. Which of the following is the initial step in evaluating this patient?

A) Repeat Prolactin after Serum Dilution

B) Discontinue Risperdal

C) Trans-Sphenoidal Resection of the Tumor

D) Pituitary Irradiation

E) Bromocriptine

Question of the Week # 389

389)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

Question of the week # 300

300) A 14 year old girl is evaluated in your office for  moderate headache of one month duration . She denies any blurred vision, neck stiffness or fever. She is accompanied by her mother who reports that her performance at school has progressively declined over the last few months and she has deepening of voice for the past 4 months. On examination, Pulse 80/min;  Temperature: 98.4F  and Blood pressure: 135/100 mm of Hg. There is excessive hair on her face. Rest of the physical is normal except for faint purplish marks on her abdomen. Laboratory investigations including complete blood count, comprehensive metabolic panel and Urine analysis are within normal limit. Which of the following is the most appropriate next step ?

A) 24 hour urinary cortisol

B) MRI brain

C) CT scan of the abdomen

D) Dexamethasone Suppression Test

E) Plasma catecholamines

F) Urine Drug Screen

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