Practice questions II Pathology of endocrine pancreas

Practice questions

Pathology of endocrine pancreas II

© Jun Wang, MD, PhD

1. Use this case for the next two questions. A 59-year-old man presents with dizziness and sweating for 2 hours. He was diagnosed with type 2 diabetes two months ago, and has been compliant with his medication. In addition, he started an aggressive diet plan to reduce weight. He skipped his breakfast and hiked 3 miles before he felt dizzy. His past medical history include hypertension and obesity. He does not drink alcohol or smoke cigarette. Physical examination reveals a BMI at 35 (normal 18-25). He appears to be slightly confused and his skin is moist. His heart rate is 135 bpm. No other abnormalities are noted. Laboratory test reveal a glucose at 52 mg/dl (normal 70-100 mg/dl) and HbA1C at 8.0% (normal 4-5.6%). Other laboratory test results are within normal range. What is the diagnosis?

A. Diabetic ketoacidosis

B. Diabetic nephropathy

C. Diabetic neuropathy

D. Hyperosmolar hyperosmotic syndrome

E. Hypoglycemia

2. A 59-year-old man presents with dizziness and sweating for 2 hours. He was diagnosed with type 2 diabetes two months ago, and has been compliant with his medication. In addition, he started an aggressive diet plan to reduce weight. He skipped his breakfast and hiked 3 miles before he felt dizzy. His past medical history include hypertension and obesity. He does not drink alcohol or smoke cigarette. Physical examination reveals a BMI at 35 (normal 18-25). He appears to be slightly confused and his skin is moist. His heart rate is 135 bpm. No other abnormalities are noted. Laboratory test reveal a glucose at 52 mg/dl (normal 70-100 mg/dl) and HbA1C at 8.0% (normal 4-5.6%). Other laboratory test results are within normal range. What is most likely causing his presentations?

A. Excess fatty acid metabolism

B. Glucagonoma

C. Insulinoma

D. Meal skipping

E. Osmotic diuresis

3. Use this case for the next two questions. A 66-year-old man presents with recurrent left leg ulcers. He has a history of type 2 diabetes for 20 years and he is not compliant to his medication and diet/exercise recommendations. He already has his left foot amputated due to non-healing ulcer. He has had hypertension and hyperlipidemia for 25 years. He smokes cigarette 1 pack a day for 45 years and drink 2 glasses of wine every day for 30 years. Physical examination reveals an 8 cm irregular ulcer at the medial side of left leg, approximately 5 cm from the ankle. 3 smaller ulcers up to 3.5 cm are seen at the lateral side, up to 10 cm from his ankle. Below-knee amputation was performed and pathological examination reveals an almost completely occluded anterior tibial artery. What is the most important factor associated with his presentations?

A. Endothelial injury due to hypertension

B. Immunodeficiency associated recurrent infection due to lymphocytic dysfunction

C. Suppressed fructose production due to oxidative stress

D. Vascular smooth muscle proliferation due to activation of advanced glycation end products receptors

4. A 66-year-old man presents with recurrent left leg ulcers. He has a history of type 2 diabetes for 20 years and he is not compliant to his medication and diet/exercise recommendations. He already has his left foot amputated due to non-healing ulcer. He has had hypertension and hyperlipidemia for 25 years. He smokes cigarette 1 pack a day for 45 years and drink 2 glasses of wine every day for 30 years. Physical examination reveals an 8 cm irregular ulcer at the medial side of left leg, approximately 5 cm from the ankle. 3 smaller ulcers up to 3.5 cm are seen at the lateral side, up to 10 cm from his ankle. Below-knee amputation was performed and pathological examination reveals an almost completely occluded anterior tibial artery. What is the most significant complication for this patient?

A. Diabetic ketoacidosis

B. End-stage renal disease

C. Hypoglycemia

D. Lung cancer

E. Sepsis

5. A 50-year-old woman presents for follow up for diabetes. She was diagnosed with type 2 diabetes a year ago. She has a history of obesity and hypertension. Physical examination reveals a BMI at 32 (normal 18-25). No other abnormalities are noted. Laboratory tests reveals positive urine albumin at 240 mg/day, and HbA1c at 7.5% (normal 4-5.6%). Her CBC is normal. No blood cells are seen in urine. Based on these findings, what disorder is this patient likely to have in near future?

A. Diabetic ketoacidosis

B. Diabetic nephropathy

C. Hyperosmolar hyperosmotic syndrome

D. Hypoglycemia

E. Insulinoma

6. Use this case for the next four questions. A 55-year-old man presents with mild polydipsia and polyuria. He has a 10 year history of type 2 diabetes. Other significant past medical history include obesity and hypertension. Physical examination reveals a BMI of 33 (normal 18-25). No other significant abnormalities are noted. His laboratory test results include a 24 hour urine albumin at 950 mg and HbA1c at 8.2% (normal 4-5.6%). No blood cells are seen in his urine. Other tests, including CBC and renal function tests are within normal range. What is most likely found in his kidney biopsy?

A. Cyst formation, stromal fibrosis and interstitial inflammation

B. Diffuse neutrophilic and lymphocytic interstitial infiltrate

C. Diffuse and nodular glomerulosclerosis

D. Epithelial proliferation with crescent formation

E. Smooth muscle proliferation

7. A 55-year-old man presents with mild polydipsia and polyuria. He has a 10 year history of type 2 diabetes. Other significant past medical history include obesity and hypertension. Physical examination reveals a BMI of 33 (normal 18-25). No other significant abnormalities are noted. His laboratory test results include a 24 hour urine albumin at 950 mg and HbA1c at 8.2% (normal 4-5.6%). No blood cells are seen in his urine. Other tests, including CBC and renal function tests are within normal range. What is the most likely associated with his proteinuria?

A. Autoantibody associated injury to glomerular endothelial and epithelial cells

B. Bacterial infection-induced nephron damage

C. Deposit of immune complex between endothelial cell and basement membrane

D. Epithelial proliferation of Bowman’s capsule

E. Increased glomerular extracellular matrix

8. A 55-year-old man presents with mild polydipsia and polyuria. He has a 10 year history of type 2 diabetes. Other significant past medical history include obesity and hypertension. Physical examination reveals a BMI of 33 (normal 18-25). No other significant abnormalities are noted. His laboratory test results include a 24 hour urine albumin at 950 mg and HbA1c at 8.2% (normal 4-5.6%). No blood cells are seen in his urine. Other tests, including CBC, albumin and renal function tests are within normal range. What is the diagnosis?

A. Chronic pyelonephritis

B. Diabetic nephropathy

C. End stage renal disease

D. Membranous glomerulonephritis

E. Postinfectious glomerulonephritis

9. A 55-year-old man presents with mild polydipsia and polyuria. He has a 10 year history of type 2 diabetes. Other significant past medical history include obesity and hypertension. Physical examination reveals a BMI of 33 (normal 18-25). No other significant abnormalities are noted. His laboratory test results include a 24 hour urine albumin at 950 mg and HbA1c at 8.2% (normal 4-5.6%). No blood cells are seen in his urine. Other tests, including CBC and renal function tests are within normal range. What is most likely to occur to this patient if nor properly treated?

A. Distant metastasis

B. End stage renal disease

C. Hypercalcemia

D. Hypoparathyroidism

E. Severe osteoporosis

10. A 41-year-old woman presents with painless progressive blurring of vision for 6 months. She has a history of Graves disease that was treated with surgery, and type 2 diabetes that was treated with hypoglycemic agent. Her mother has cataract. Physical examination is unremarkable, except findings consistent with previous thyroid surgery. She has equal pupils with normal direct and consensual pupillary reflexes bilaterally. Intraocular pressure is within normal range. Fundus examination reveals dilated veins and a few pale spots on both retina. The optic discs are normal. The cornea, lens, iris and vitreous are unremarkable. What is the diagnosis?

A. Cataract

B. Diabetic optic neuropathy

C. Diabetic retinopathy

D. Glaucoma

E. Thyroid oculopathy

11. Use this case for the next three questions.  A 55-year-old man presents with recurrent episodes of diaphoresis, tremors and palpitation. These episodes were relieved after taking some food. His past medical history including hyperlipidemia and obesity. He denies cigarette, alcohol or illicit drug usage. Physical examination is unremarkable except a BMI at 34 (normal 18-25). Laboratory test results include a random plasma glucose at 52 mg/dl (normal 70-100 mg/dl), insulin at 65 microIU/ml (normal 2.6-24.9 microIU/ml) and C-peptide at 6.3 ng/ml (normal 0.8-4.2 ng/ml). What is the next step that will most likely yield a diagnosis?

A. Abdominal image studies

B. Blood toxicology screen

C. EKG

D. Glucose tolerance test

E. Head CT

12. A 55-year-old man presents with recurrent episodes of diaphoresis, tremors and palpitation. These episodes were relieved after taking some food. His past medical history including hyperlipidemia and obesity. He denies cigarette, alcohol or illicit drug usage. Physical examination is unremarkable except a BMI at 34 (normal 18-25). Laboratory test results include a random plasma glucose at 52 mg/dl (normal 70-100 mg/dl), insulin at 65 microIU/ml (normal 2.6-24.9 microIU/ml) and C-peptide at 6.3 ng/ml (normal 0.8-4.2 ng/ml). What is most likely causing his presentations?

A. Diabetic ketoacidosis

B. Endogenous insulin overproduction

C. Excessive physical exertion

D. Exogenous insulin overdose

E. Meal skipping

13. A 55-year-old man presents with recurrent episodes of diaphoresis, tremors and palpitation. These episodes were relieved after taking some food. His past medical history including hyperlipidemia and obesity. He denies cigarette, alcohol or illicit drug usage. Physical examination is unremarkable except a BMI at 34 (normal 18-25). Laboratory test results include a random plasma glucose at 52 mg/dl (normal 70-100 mg/dl), insulin at 65 microIU/ml (normal 2.6-24.9 microIU/ml) and C-peptide at 6.3 ng/ml (normal 0.8-4.2 ng/ml). Abdominal CT study reveals a 2.5 cm well-defined mass at pancreas body. CT-guided biopsy reveals solid cords of small cells with round to oval nuclei in a background of amorphous material that is positive for Congo red. No significant atypia is noted. Immunohistochemistry studies reveal these cells are positive for cytokeratin and negative for CD45. What is the diagnosis?

A. Glucagonoma

B. Insulinoma

C. Pancreatic adenocarcinoma

D. Plasmacytoma

E. Small lymphocytic lymphoma

14. Use this case for the next two questions.  A 66-year-old man presents with diffuse erythematous pruritic rash for 3 months. He has lost 15 pound unintentionally. He has a history of hypertension. Physical examination reveals ring-shaped scaly rash with focal ulceration. No other abnormalities are noted. Laboratory tests results include: Hb 8.5 g/dl (normal 13.5-17.5 g/dl), HbA1c 12% (normal 4-5.6%) and glucose at 180 mg/dl (normal 70-100 mg/dl). Other laboratory tests are within normal range. Microbiology studies for the skin rash reveals no evidence of fungal infection. Radiological examination reveals a poorly circumscribe mass at the pancreatic body. What additional factor is most likely to be elevated in his blood?

A. C peptide

B. CA19.9

C. Gastrin

D. Glucagon

E. Insulin

15. A 66-year-old man presents with diffuse erythematous pruritic rash for 3 months. He has lost 15 pound unintentionally. He has a history of hypertension. Physical examination reveals ring-shaped scaly rash with focal ulceration. No other abnormalities are noted. Laboratory tests results include: Hb 8.5 g/dl (normal 13.5-17.5 g/dl), HbA1c 12% (normal 4-5.6%) and glucose at 180 mg/dl (normal 70-100 mg/dl). Other laboratory tests are within normal range. Microbiology studies for the skin rash reveals no evidence of fungal infection. Radiological examination reveals a poorly circumscribe mass at the pancreatic body. What is most likely the diagnosis?

A. Glucagonoma

B. Insulinoma

C. Pancreas adenocarcinoma

D. Type 2 diabetes

E. Zollinger-Ellison Syndrome

16. A 25-year-old man presents with intermittent epigastric pain, vomiting and 18 lb unintentionally weight loss for 2 months. He has a history of type 1 diabetes, gastroesophageal reflux and chronic gastritis. Physical examination and routine laboratory tests are unremarkable. Upper endoscopic examination reveals multiple gastric and duodenal ulcers up to 1.5 cm in greatest dimension. Biopsy of the ulcers reveal benign ulcer with no Helicobacter infection. Abdominal CT examination reveals a 2.5 cm well defined mass at the tail of pancreas. Additional laboratory test reveals a gastrin level at 900 pg/ml (normal 15-113 pg/ml). What is most likely the diagnosis?

A. Glucagonoma

B. Insulinoma

C. Pancreas adenocarcinoma

D. Peptic ulcer

E. Zollinger-Ellison Syndrome

17. Use this case for the next two questions.  A 55-year-old man presents with fatigue, watery diarrhea and an unintentional 20 lb weight loss for 3 months, after a trip abroad. He denies abdominal pain, fever or other symptoms. He has a history of type 2 diabetes, hypertension and hyperplastic polyps of colon. Physical examination reveals slight dehydration. His heart rate is 110 bpm. No other abnormalities are noted. Laboratory tests reveal blood K⁺ at 2.5 mmol/L (normal 3.5 – 5.2 mmol/L). Stool microbiology studies are negative. Abdominal CT reveals a 4.4 cm mass at the tail of his pancreas. What additional factor is most likely to be elevated in his blood?

A. C peptide

B. CA19.9

C. Gastrin

D. Glucagon

E. Vasoactive intestinal polypeptide

18. A 55-year-old man presents with fatigue, watery diarrhea and an unintentional 20 lb weight loss for 3 months, after a trip abroad. He denies abdominal pain, fever or other symptoms. He has a history of type 2 diabetes, hypertension and hyperplastic polyps of colon. Physical examination reveals slight dehydration. His heart rate is 110 bpm. No other abnormalities are noted. Laboratory tests reveal blood K⁺ at 2.5 mmol/L (normal 3.5 – 5.2 mmol/L). Stool microbiology studies are negative. Abdominal CT reveals a 4.4 cm mass at the tail of his pancreas. Additional laboratory studies reveals a gastrin at 45 pg/ml (normal 15-113 pg/ml) and vasoactive intestinal peptide at 2575 pg/ml (normal <75 pg/ml). What is the diagnosis?

A. Chronic gastroenteritis

B. Insulinoma

C. Pancreas adenocarcinoma

D. VIPoma

E. Zollinger-Ellison Syndrome

Answers

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