The answer is d Fauci 14e pp 21162118 Gynecomastia is

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seen in 50-60% of adolescent boys and usually occurs during Tanner stages 2 or 3. It is usually painful and may be unilateral or bilateral. It gradually appears and gradually disappears within 1 year of onset. Pubertal changes that occur during Tanner stages 2 and 3 include growth spurt, growth of testes and penis, spermarche, acne, axillary perspiration, and appearance of pubic hair. The boy in this case should be reassured and followed monthly. If the gynecomastia does not resolve, it will be necessary to rule out Klinefelter syndrome, adrenal tumors, gonadal tumors, hyperthy-roidism, hepatic disorders, and the use of drugs, especially marijuana and bodybuilding steroids.

269. The answer is c. (Fauci, 14/e, p 1976. Tierney, 39/e, p 1070.) Patients may use anabolic steroids to improve athletic performance. The risks associated with use of these agents include mood swings, aggressiveness, paranoid delusions, psychosis, gynecomastia, infertility, testicular atrophy, hepatic tumors, peliosis hepatis, hypertension, and decreased HDL cholesterol levels. Patients with prolactinomas (pituitary tumors) generally present with galactorrhea, reduced libido, erectile dysfunction, amenorrhea, infertility, and visual field defects. Chronic cocaine use may cause hyperprolactinemia. Kallman syndrome is characterized by cleft palate, impaired sense of smell, short 4th metacarpal bones, hypogo-nadism, and infertility.

270. The answer is c. (Fauci, 14/e, p 2109.) Pregnancy (secondary amenorrhea) must always be considered in any patient who presents with amenorrhea. It is normal for prolactin levels to be elevated during pregnancy.

271. The answer is c. (Fauci, 14/e, pp 2057-2059.) Pheochromocy-toma is a life-threatening disease if left undiagnosed. Patients present with episodic symptoms of headache, sweating, and palpitations. Pheochromo-cytoma may be associated with von Recklinghausen syndrome, neurofibromatosis, and von Hippel-Lindau's disease. The diagnosis is made by 24-h urine for catecholeamines and metanephrines. Ten percent of pheochro-mocytomas are bilateral and 10% are extraadrenal. Increased levels of 5-HIAA are associated with carcinoid syndrome (facial flushing and diarrhea) from a tumor usually located in the lung or ileum. Patients with thyroid storm present with nausea, diarrhea, jaundice, fever, dyspnea, shortness of breath, diaphoresis, delirium, and tachyhcardia. The combination of diabetes mellitus, hypertension, obesity, insulin resistance, and dyslipidemia (increased VLDL, increased triglyceride, and decreased HDL) is called syndrome X or Coronary artery disease, Hypertension, Atherosclerosis, Obesity, and Stroke (CHAOS).

272. The answer is d. (DeGowin, 6/e, pp 212-213.) Simple goiter, if sufficiently large, may be accompanied by tracheal compression, esophageal compression, dysphagia, odynophagia, mediastinal obstruction, and superior vena cava syndrome. Retrosternal goiter may cause the mediastinal obstruction and superior vena cava syndrome.

273. The answer is e. (Fauci, 14/e, pp 2227-2230.) Primary hyper-parathyroidism is the most common cause of hypercalcemia in the outpatient setting. It is seen more frequently in women than men and is usually due to one parathyroid adenoma (usually in the inferior lobe). Patients often have a history of hypophosphatemia, fatigue, hypertension, depression, peptic ulcer disease, pancreatitis, bone pain, hypercalciuria, and nephrolithiasis from calcium oxalate stones. The most common cause of hypercalcemia in hospitalized patients is malignancy (i.e., breast, lung, multiple myeloma, head and neck, and renal cell) due to the secretion of PTH-related peptide (PTHrp). Patients with familial hypocalciuric hypercalcemia (FHH) have hypocalciuria, a positive family history, and no end organ damage. Other causes of hypercalcemia include sarcoidoisis, mycobacteria, milk-alkali syndrome, and medications (i.e., thiazide diuretics). Osteitis fibrosa cystica (replacement by fibrous tissue) is the bone abnormality seen with hyperparathyroidism.

274. The answer is c. (Seidel, 4/e, pp 120-121.) There are five Tanner stages:

Tanner 1 = Young child penis, scrotum, and testes; no pubic hair Tanner 2 = Enlargement of scrotum and testes; penis the same; scrotal skin becomes more red, thinner, and wrinkled; some straight pubic hair at base of penis Tanner 3 = Enlargement of penis and testes; scrotum descends; dark, curly pubic hair

Tanner 4 = Further penile enlargement; increased pigmentation of scrotum; sculpturing of the glans; adult pubic hair but not beyond inguinal fold

Tanner 5 = Ample scrotum; penis reaches to bottom of scrotum; hair spreads to medial surface of thighs

275. The answer is a. (Tierney, 39/e, pp 1152-1157.) Hyperosmolar hyperglycemic nonketotic state (HHNKS) is seen in patients with NIDDM and is usually precipitated by an illness. The patient's residual insulin prevents lipolysis and ketogenesis. Diabetic ketoacidosis (DKA) is due to an absolute deficiency of insulin relative to the counter-regulatory hormones. The result is gluconeogenesis, ketogenesis, lipolysis, and decreased glucose uptake causing hyperglycemia and a metabolic acidosis. Kussmaul respiration is a respiration pattern of increased tidal volume seen in patients with metabolic acidosis (i.e., DKA). Gestational diabetes occurs in 3% of pregnancies; all women should be screened between the 24th and 28th wk of pregnancy. Complications of undiagnosed gestational diabetes include macrosomia and neonatal hypoglycemia. Impaired glucose tolerance is defined as a 2-h plasma glucose of 140-200 mg/dL after a glucose load of 75 g in a patient whose fasting blood glucose is normal.

Glucose intolerance is due to a combination of insulin resistance and impaired insulin secretion. Patients with barbiturate overdose generally present with hypoglycemia.

276. The answer is e. (Tierney, 39/e, pp 1180-1183, 2136.) The patient most likely has a rash seen in diabetic patients called necrobiosis lipoidica diabeticorum. Acanthosis nigricans is a velvety, hyperpigmented, thickened skin lesion over the dorsum of the neck, axillae, and groin and often precedes the diagnosis of an endocrine (insulin-resistant) disorder. Patients with DM must be evaluated for both macrovascular and microvascular complications.

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