Endocrinology. Final test
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Patients with diabetes mellitus complicated by neuropathy should be taught:
To visually inspect their feet daily Never to walk barefoot, even in the house To soak their feet to aid in healing foot ulcers Options a and b All of the above How often should a glycosilated haemoglobin (A1C,%) be drawn in patient with diabetes mellitus? An A1C can be drawn monthly in patients whose therapy has just changed or who are not meeting glycemic control. In patients who are at glycemic control, it can be drawn four times a year An A1C can be drawn quarterly in patients whose therapy has just changed or who are not meeting glycemic control. In patients who are at glycemic control, it can be drawn once a year An A1C can be drawn quarterly in patients whose therapy has just changed or who are not meeting glycemic control. In patients who are at glycemic control, it can be drawn twice a year Which of the following treatments have controlled trials shown to be beneficial for persons with type 2 diabetes mellitus and early nephropathy? Tight blood pressure control that includes an dihydropyridine-sensitive calcium channel blocker Tight blood pressure control that includes an angiotensin-converting enzyme inhibitor Tight blood pressure control that includes a potassium sparing diuretic Dialysis 76. A patient V., 55 year old man is evaluated in the emergency department with worsening acute abdominal pain and a 2-day history of recurrent vomiting. He has had Type 2 diabetes for 12 years that is currently treated with glybenclamid 5 mg twice daily and metformin 1000 mg twice daily. He takes lizinopril 20 mg daily for hypertension. His most recent hemoglobin A1c level, assessed 2 months ago, was 8,8%. He does not often self-monitor his blood glucose and does not follow his diet very well. He has gained 6.8 kg during the past year. Objectively: Body mass index (BMI) is 33 kg/m². His temperature is 37.7 °C and blood pressure is 120/70 mm Hg. He has diffuse yellowish-orange lesions on his elbows and back. Tenderness is noted in the epigastric area. Laboratory studies: Leukocyte - 12.4 × 109/L, creatinine – 185,68 mmol/L, total cholesterol – 8,28 mmol/L, triglycerides – 43,47 mmol/L. Glucose – 23,31 mmol/L. Which of the following should be considered in the immediate management of this patient's diabetes? A. Discontinue lizinopril B. Start atorvastatin C. Start fenofibrate D. Start intravenous insulin E. Start NPH insulin twice daily with a correction dose of rapid-acting insulin Patient 30 years is being ill by Diabetes Mellitus for 10 years. He accepts the insulin in a dose 46 IU in two injections. There are frequent hypoglycemic comas, decline of the sight, pain in lower extremities in anamnesis. The microaneurisms, hemorrhage, expansion of veins of the retina are determined on the eyeing bottom. The fasting level of glucose is 13,2 mmol/L. What is your previous diagnosis? Type 1diabetes mellitus, diabetic background retinopathy, diabetic foot syndrome Type 2 diabetes mellitus, diabetic proliferative retinopathy, diabetic foot syndrome Type 1diabetes mellitus, diabetic proliferative retinopathy, diabetic neuropathy Type 1 diabetes mellitus, diabetic preproliferative retinopathy, diabetic neuropathy, diabetic nephropathy Non of this variant A patient W., which is ill for 15 years by type 1 Diabetes Mellitus, during last year determine weakness, hypertension, swelling of lower limbs and face. Lab studies: analysis of urine: albumin – 0,99 g/L, glucose 11 mmol/L, leukocyte 3 – 5, creatinine, urea are normal. The fasting level of glucose – 11,5 mmol/L. Established the most suitable diagnose: A. Type 1 diabetes mellitus, inadequate control, diabetic nephropathy, persistent proteinuria B. Type 1 diabetes mellitus, adequate control, diabetic nephropathy, persistent proteinuria C. Type 1 diabetes mellitus, adequate control, diabetic nephropathy, renal impairment D. Type 1 diabetes mellitus, inadequate control, diabetic nephropathy, microalbuminuria E. Non of this variant A patient 32 years, for the first time diagnosed the type 1Diabetes Mellitus, complained of hypersensitive in the both of legs, especially in the region of thighs, touch of the clothes caused unbearable pain. Connecting appearance of pain with symptoms of diabetes mellitus and lost of weight. Your preliminary diagnosis? Type 1 diabetes mellitus, diabetic distal symmetrical sensorimotor polyneuropathy Type 1 diabetes mellitus, diabetic angiopathy Type 1 diabetes mellitus, diabetic autonomic neuropathy Type 1 diabetes mellitus, diabetic amyotrophy Non of this variant Patient 42 years old is ill by type 1 Diabetes Mellitus, entered permanent establishment with complaints about the loss of the weight, growing the weakness. He ills by diabetes mellitus for a year. He treats by insulin in a dose 12 IU Humudari R of rapid action and 18 IU Humudari B of prolong action. Diabetes mellitus is stable, hypoglycemia is not present. Objectively: considerable grow thin, especially muscles. Pulsation on the distal parts of arteries of the feet is good, the trophic changes are not exposed. Achilles' and knee’s reflexes are considerably slow from the both sides. Vibration, tactile, thermal sensitiveness are not damage. Your previous diagnosis? Type 1 diabetes mellitus, asthenia of somatogene Type 1 diabetes mellitus, peripheral polyneuropathy Type 1 diabetes mellitus in the stage of decompensation Type 1 diabetes mellitus, total motor polyneuropat Type 1 diabetes mellitus, total sensor polyneuropathy Patient M., 33 years old, after a stressful incident, presented with weakness, a 10 kg weight loss despite good appetite, feeling of inner tension, irritability, emotional lability, sweating, tachycardia, tremor, menstrual irregularity, diarrhea. Objective review: pulse 110 per min. Blood pressure - 130/65, cardiac tones normal, skin is moist, warm, thyroid gland enlarged, with a firm and homogenous mass. Substantiate diagnosis: Hashimoto thyroiditis Diffuse toxic goiter Diffuse nontoxic goiter Nodular goiter Sporadic diffuse nontoxic goiter Patient L., 26 years old, during 3 months was ill diffuse toxic goiter III, to treatment – thyrozol 20 mg per day. After tooth extraction the patient complaints: palpitations, tremor, high fever, diarrhea. Objective review: thyroid gland enlarged, smooth, normal texture homogenous. Abdominal pain, vomiting. Tachycardia – 140 beats/min, blood pressure 140/50. Fever – 40 ° C. Establish your diagnosis: Thyrotoxic crisis Thyrotoxic hepatitis Pneumonia Adrenal crisis Acute pancreatitis Patient U., 26 years old, complains of swallowing, weakness, feeling of a “loop” round the neck. In anamnesis – 10 years ago was treatment goiter. Objective review: thyroid gland enlarged III grade, normal texture, homogenous. Periorbital puffiness, Stellwag's, Dalrymple's, Rosenbach's signs are negative. Result of ultrasound examination: a thyroid gland is increased, total size is 36 cm³, echogenicity is not changed. Level of thyroid hormones are normal. Median of iodine excretion with urine 100 mkg/l. Substantiate diagnosis: Nodular goiter Endemic diffuse nontoxic goiter of 3 grade Diffuse nontoxic goiter of 2 grade Sporadic diffuse nontoxic goiter of 2 grade Diffuse euthyroid goiter of 2 grade A previously healthy 19 year old female complains of a fast heart rate, weight loss, and fatigue over the past 2 months. Her family history is significant for a grandmother and aunt with Hashimoto thyroiditis. Objective review: temperature - 37,0° C, pulse - 110 beats/min, blood pressure - 120/50, cardiac tones normal, skin is moist, warm, a mild tremor. Thyroid gland enlarged, smooth, normal texture and homogenous. High level of T3 and T4, undetectable TSH. Thyroid stimulating immunoglobulin assay is positive. Your diagnosis? Graves’ disease Hashimoto thyroiditis Diffuse nontoxic goiter Nodular goiter Sporadic diffuse nontoxic goiter A 24 years old woman with chronic schizophrenia is referred for evaluation of abnormal thyroid function tests after experiencing an acute exacerbation of psychosis. She has no prior history of thyroid dysfunction but several family members have been affected by autoimmune thyroid disease. Over the preceding three months she has lost 8 kg and has noted insomnia, tachycardia, heat intolerance, and irregular menses. Physical examination demonstrates an anxious and restless young woman with resting tachycardia (rate 120 beats/min), tremor of extended fingers, bilateral lid lag and “stare”, warm moist skin, brisk reflexes, and an impalpable thyroid gland. Thyroid function tests are as follows: free T 4 - 4,2 ng / dL (normal 0,8 – 2,0 ng / dL), TSH < 0,01 μU / L (normal 0,4 – 4,5 μU / L), thyroglobulin – 5 ng / mL (normal < 40 ng / mL). Which diagnosis is most likely? Nervous exhaustion Adenoma of thyroid gland Struma ovarii Diffuse toxic goiter Nodular goiter Patient A., 38 years old. Operated a diffuse toxic goiter. After the operation the state a patient became worse, palpitation, shortness of breath, diarrhea, fever. Objective review: fever is 38.6°С, pulse - 160 beats/min, blood pressure - 85/40. Preliminary diagnosis: Thyrotoxic crisis Thyrotoxic hepatitis Pneumonia Adrenal crisis Acute pancreatitis The patient M. is 55, appealed with complaints about the increase of thyroid. From the inspections the diffuse increase of thyroid is exposed to 2 grade, function is abnormal: high level of T3 and T4, undetectable TSH. The treatment of diffuse toxic goiter first of all usually include. Choose agent, which inhibits synthesis of thyroid hormones: Thiamazole Potassium perchlorate Potassium iodide Iopanoic acid Dexamethasone A 50 year old man presents with enlargement of left anterior neck. He has noted increased appetite over past month with no weight gain, and more frequent bowel movements over the same period. Physical examination: temperature of 37,4 °С, the heart rate is 92 and the blood pressure is 110/50. There is an ocular stare with a slight lid lag. The thyroid gland is enlargement of 3 grade and asymmetric to palpation, nodule in left lobe of the thyroid gland. Result of ultrasound examination: a thyroid gland is increased, total size is 40 cm³, there is a 3 x 2.5 cm firm nodule in left lobe of the thyroid. Level of thyroid hormones are abnormal: high level of T3 and T4, undetectable TSH. Which diagnosis is most likely? Adenoma of thyroid gland Nodular goiter 3 grade, thyrothoxicosis Multinodular goiter Diffuse toxic goiter Nodular goiter Patient V., 26 years old, during 3 months was ill diffuse toxic goiter III, to treatment – thyrozol 30 mg per day. After grippe the patient complaints: palpitations, tremor, high fever, diarrhea. Objective review: thyroid gland enlarged, smooth, normal texture homogenous. Abdominal pain, vomiting. Tachycardia – 140 beats/min, blood pressure 140/50. Fever – 40 ° C. Establish your diagnosis? Diffuse toxic goiter in decompensation. Thyrotoxic crisis. Nodular goiter Toxic goiter in pregnancy Adenoma of thyroid gland Diffuse toxic goiter in compensation A 53 year old woman came to the polyclinic. She had no symptoms but gave a history of a lump in her neck being noticed by her primary care physician during a routine ‘well-woman’ check. There was no family history of thyroid disease and she had a blameless past medical history. She had not noticed any change in her voice, or difficulty swallowing or breathing. Examination was entirely normal, except thyroid gland enlarged II grade, normal texture, homogenous for a 3 × 2 cm single nodule in the left lower thyroid gland. Blood tests showed that her total T4, free T3, TSH - normal, and thyroid autoantibodies were not present in serum. What is the probable diagnosis? Nodular goiter Endemic diffuse nontoxic goiter Diffuse nontoxic goiter Sporadic diffuse nontoxic goiter Diffuse euthyroid goiter A female, 62 years old, suffers from pernicious anaemia for which she has received 1 mg cyanocobalamine intramuscularly every 3 month for the last 10 years. At a routine visit the patient is found with a puffy swollen face due to a non-pitting edema. Her skin is dry and cold, the heart rate is 55 beats/ min, her hair is sparse, and she complains of constipation and fatigue. A series of blood tests reveals the following: high levels of microsomal autoantibodies against the thyroid gland and autoantibodies against her parietal cells. The TSH concentration in the plasma is high, whereas the T3, T4 are low. The haematological variables are satisfying. What is the probable diagnosis? Hypothyroidism Cardiac insufficiency Pernicious anaemia Autoimmune (Hashimotos) thyroiditis, hypothyroidism Nephrotic syndrome A 28 year old woman with recent tiredness and difficulty concentrating had experienced a decline in memory over the last several months. She also noted decreased frequency of bowel movements and an increased tendency to gain weight. She felt chilled without light sweater, even in warm weather. In the anamnesis - hypothyroidism in her mother and older sister. Objectively: She had a slightly puffy face and her eyebrows were sparse, especially at the lateral margins. The thyroid gland is not palpated. Heart rate – 58 beats/min, BP is 100/60 mmHg. Tones of heart of low sonority. The deep tendon reflexes were normally contractive, but showed delayed relaxation. What laboratory tests would you order to evaluate this patient? Ultrasound thyroid gland Test for anti-thyroid antibodies (anti-thyroglobulin and anti-microsomal) Blood tests: levels T3, T4 and TSH ECG All methods 93. At patient M., 29 years old, the asymmetric increase of thyroid gland of the II stage is exposed, a gland is painful at palpation, pain irradiates in a left ear and upper jaw. Temperature of the body - 38,7 °C. A week ago carried a tonsillitis. Most reliable that patient has: Fibrotic thyroiditis Diffuse toxic goiter Autoimmune thyroiditis Subacute thyroiditis Toxic adenoma of thyroid gland The patient N., 26 years old complains of the increase of body mass, weakness, constipations, worsening of memory, some lowering of the voice and increase in fatigue. After delivery, she nursed the infant for 1 week. She then stopped nursing, but galactorrhea and amenorrhea continued for the next 5 months. In the anamnesis - she had menarche at age 16 and had regular periods. She married at age 24 and was not able to conceive. After receiving therapy for 7 months for treatment of extensive endometriosis, she became pregnant and delivered after 36 weeks' gestation. Her sister had autoimmune thyroiditis. Objectively: a skin by touch is dry. A thyroid gland is enlarged II grade, smooth surface. Pulse – 58 beats/min, diminished sonority of tones of heart. The laboratory results: high levels of microsomal autoantibodies against the thyroid gland, the levels of TSH and prolactin were elevated, low levels of T3, T4. What is the diagnosis? Autoimmune thyroiditis, hypothyroidism Diffuse nontoxic goiter Autoimmune thyroiditis without violation of the thyroid gland function Hypothyroidism Syndrome of Van – Vik – Ross – Geness A female, 72 years old in the grave condition hospitalization on emergency. Objectively: Temperature of the body - 35,8 °C. Blood pressure – 80/50 mmHg, pulse - 56 beats/min, diminished sonority of tones of heart, breathing - 12 /min. A skin is pale, cold, moderate edema of face and extremities. The hairs are liquid, thin, on a head areas of alopecia. Most reliable that patient has: Addisonic crisis Myxedema coma Lactacidotic coma Hypoglycemic coma Hypocalcemia A patient B., 59 years old complains of the presence of nodule on the front surface of neck. Became ill 3 years ago. A nodule was enlarged in sizes, the timbre of voice changed, feeling of pressure appeared. Objectively: in the right lobe of thyroid a nodule is palpated 5 cm in a diameter, painless. The functional state of thyroid is not changed. What is the diagnosis? Nodular euthyreoid goiter Nodular hyperthyroid goiter Cancer of thyroid gland Chronic lymphomatous Hashimoto thyroiditis Chronic fibrous Ridel's thyroiditis At a patient M., 45 years old at the palpation of thyroid gland a nodule 2,0 х 3,2 cm is exposed in a left lobe, compacted, moderately painful during palpation. "Cold" nodule at scyntygrafia with I131. What inspection is most expedient for clarification of diagnosis? Ultrasound of thyroid gland Aspirational biopsy Determination of the TSH, T3 and T4 level in a blood Immunodetection Computed tomography scan (CT-scan) of thyroid gland |