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A 36-year-old female presents to the office complaining of difficulty losing weight. She seeks a prescription drug to aid in efforts to lose unwanted weight she has been gaining for 2 years. She has tried every fad diet she comes across, but nothing seems to help. She tries to exercise regularly, but manages only walking a couple of miles each week. A nutritional history reveals that she is eating a sensible low-fat diet. Her past medical history includes hypertension treated with medications for the last 3 years and non-insulin-dependent diabetes mellitus for the last year. She has also been seeing a psychiatrist over the last 6 months for emotional lability, which she blames on anxiety over her inability to get pregnant. The patient takes glyburide 5 mg PO daily and benazepril (Lotensin) 40 mg PO daily. A review of systems reveals thinning hair, irregular menses, delayed wound healing, and infertility.
What dietary advice can you offer this patient? |
| | A) | She is eating right, she just needs to exercise more. |
| | B) | Low-fat diets are ineffective; she needs to reduce her carbohydrate intake. |
| | C) | She has failed lifestyle modifications, and appetite suppressant medications are indicated. |
| | D) | She is likely depressed, and needs to continue psychiatric therapy and probably should start treatment with an SSRI. |
| | E) | Reserve any dietary advice at this time, as she first needs a medical workup. |
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The rest of the physical exam is unremarkable. Based on this patient’s history and physical exam, what diagnosis is most likely? |
| | A) | Hypothyroidism. |
| | B) | Hyperthyroidism. |
| | C) | Cortisol excess secondary to chronic steroid therapy. |
| | D) | Cortisol excess secondary to an endogenous process (Cushing’s disease). |
| | E) | Cortisol deficiency secondary to autoimmune adrenal insufficiency. |
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3 | |
Laboratory findings are as follows: Na 142 meq/L, K 2.9 meq/L, Cl 112 meq/L, CO2 30 meq/L, BUN 14 mg/dL, Cr 1.1 mg/dL, Glucose 210 mg/dL; 24-hour urinary free cortisol: 115 _g (normal < 100 _g).
Based on these findings, a dexamethasone suppression test is ordered. The patient is given dexamethasone for 2 days, and then serum ACTH is drawn, and another 24-hour urine collection is done. The results are: Serum ACTH, Normal; 24-hour urinary free cortisol: 78 _g (normal).
What is the source of this patient’s cortisol excess? |
| | A) | An ACTH-producing tumor. |
| | B) | A cortisol-producing adrenal tumor. |
| | C) | Surreptitious use of oral steroids. |
| | D) | Not enough information to determine. |
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4 | |
On physical exam, the patient has a visual field cut. What is the best next step in this patient’s evaluation? |
| | A) | Ultrasound of kidneys to assess for masses and adrenal flow. |
| | B) | CT scan of the brain to rule out metastatic lesions and assess pituitary size. |
| | C) | CT scan of the adrenals to evaluate for adrenal neoplasms. |
| | D) | MRI of the pancreas to evaluate for neoplasms. |
| | E) | MRI of the pituitary gland to evaluate for a neoplasm. |
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