1. The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, glomerular filtration rate, autoregulation, and related hormone factors regulating renal blood flow Question: What would be the most important concept of hormonal regulation that the APRN should address? 2. The APRN is giving a pathophysiology lecture to APRN students on renal blood flow, related hormones, and glomerular filtration rate.   Question: What would be the most important concept of glomerular filtration rate that the APRN should address? A 46-year-old Caucasian female presents to the PCP’s office with a chief complaint of severe, intermittent right upper quadrant pain for the last 3 days. The pain is described as sharp and has occurred after eating french fries and cheeseburgers and radiates to her right shoulder. She has had a few episodes of vomiting “green stuff”. States had fever and chills last night which precipitated her trip to the office. She also had some dark orange urine, but she thought she was dehydrated.   Physical exam: slightly obese female with icteric sclera as well as generalized jaundice. Temp 101˚F, pulse 108, respirations 18. Abdominal exam revealed rounded abdomen with slightly hypoactive bowel sounds. + rebound tenderness on palpation of right upper quadrant. No tenderness or rebound in epigastrium or other quadrants. Labs demonstrate elevated WBC, elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5 mg/dl.  Abdominal ultrasound demonstrated enlarged gall bladder, dilated common bile duct and multiple stones in the bile duct. The APRN diagnoses the patient with acute cholecystitis and refers her to the ED for further treatment.  Question 1 of 2: Describe how gallstones are formed and why they caused the symptoms that the patient presented with.  Question 2 of 2: Explain how the patient became jaundiced 3. Ruth is a 49-year-old office worker who presents to the clinic with a chief complaint of abdominal pain x 2 days. The pain has significantly increased over the past 6 hours and is now accompanied by nausea and vomiting. The pain is described as “sharp and boring” in mid epigastrum and radiates to the back. Ruth admits to a long history of alcohol use, and often drinks up to a fifth of vodka every day.   Physical Exam: Temp 102.2F, BP 90/60, respirations 22. Pulse Oximetry 92% on room air.  General: thin, pale white female in obvious pain and leaning forward. Moving around on exam table and unable to sit quietly.  CV-tachycardic. RRR without gallops, rubs, clicks or murmurs  Resp-decreased breath sounds in both bases with poor inspiratory effort  Abd- epigastric guarding with tenderness. No rebound tenderness. Negative Cullen’s and + Turner’s signs observed.  Hypoactive bowel sounds x 2 upper quadrants, and no bowel sounds heard in both lower quadrants.   The APRN makes a tentative diagnosis of acute pancreatitis based on history and ph.

1. 1. The APRN is giving a pathophysiology lecture to APRN
students on renal blood flow, glomerular filtration rate,
autoregulation, and related hormone factors regulating renal
blood flow
Question:
What would be the most important concept of hormonal
regulation that the APRN should address?
2. The APRN is giving a pathophysiology lecture to APRN
students on renal blood flow, related hormones, and glomerular
filtration rate.
Question:
What would be the most important concept of glomerular
filtration rate that the APRN should address?
A 46-year-old Caucasian female presents to the PCP’s office
with a chief complaint of severe, intermittent right upper
quadrant pain for the last 3 days. The pain is described as sharp
and has occurred after eating french fries and cheeseburgers and
radiates to her right shoulder. She has had a few episodes of
vomiting “green stuff”. States had fever and chills last night
which precipitated her trip to the office. She also had some dark
orange urine, but she thought she was dehydrated.
Physical exam: slightly obese female with icteric sclera as well
as generalized jaundice. Temp 101˚F, pulse 108, respirations
18. Abdominal exam revealed rounded abdomen with slightly
hypoactive bowel sounds. + rebound tenderness on palpation of
right upper quadrant. No tenderness or rebound in epigastrium
or other quadrants. Labs demonstrate elevated WBC, elevated

2. serum alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5
mg/dl. Abdominal ultrasound demonstrated enlarged gall
bladder, dilated common bile duct and multiple stones in the
bile duct. The APRN diagnoses the patient with acute
cholecystitis and refers her to the ED for further treatment.
Question 1 of 2:
Describe how gallstones are formed and why they caused the
symptoms that the patient presented with.
Question 2 of 2:
Explain how the patient became jaundiced
3. Ruth is a 49-year-old office worker who presents to the
clinic with a chief complaint of abdominal pain x 2 days. The
pain has significantly increased over the past 6 hours and is now
accompanied by nausea and vomiting. The pain is described as
“sharp and boring” in mid epigastrum and radiates to the back.
Ruth admits to a long history of alcohol use, and often drinks up
to a fifth of vodka every day.
Physical Exam: Temp 102.2F, BP 90/60, respirations 22. Pulse
Oximetry 92% on room air.
General: thin, pale white female in obvious pain and leaning
forward. Moving around on exam table and unable to sit
quietly.
CV-tachycardic. RRR without gallops, rubs, clicks or murmurs
Resp-decreased breath sounds in both bases with poor
inspiratory effort

3. Abd- epigastric guarding with tenderness. No rebound
tenderness. Negative Cullen’s and + Turner’s signs observed.
Hypoactive bowel sounds x 2 upper quadrants, and no bowel
sounds heard in both lower quadrants.
The APRN makes a tentative diagnosis of acute pancreatitis
based on history and physical exam and has the patient
transferred to the ER where laboratory and radiographic exams
reveal acute pancreatitis.
Question:
Explain how pancreatitis develops and the role alcohol played
in this patient’s case.
1.
A 67-year-old Caucasian woman was brought to the clinic by
her son who stated that his mother had become slightly confused
over the past several days. She had been stumbling at home and
had fallen once but was able to ambulate with some difficulty.
She had no other obvious problems and had been eating and
drinking. The son became concerned when she forgot her son’s
name, so he thought he better bring her to the clinic.
PMH-Type II diabetes mellitus (DM) with peripheral
neuropathy x 20 years. COPD. Depression after death of spouse
several months ago
Social/family hx - non contributary except for 30 pack/year
history tobacco use.
Meds: Metformin 500 mg po BID, ASA 81 mg po qam,
escitalopram (Lexapro) 5 mg po q am started 2 months ago

4. Labs-CBC WNL; Chem 7- Glucose-92 mg/dl, BUN 18 mg/dl,
Creatinine 1.1 mg/dl, Na+120 mmol/L,
K+4.2 mmol/L, CO237 m mol/L, Cl-97 mmol/L.
The APRN refers the patient to the ED and called endocrinology
for a consult for diagnosis and management of syndrome of
inappropriate antidiuretic hormone (SIADH).
Question:
Define SIADH and identify any patient characteristics that may
have contributed to the development of SIADH
QUESTION 2
1. A 43-year-old female presents to the clinic with a chief
complaint of fever, chills, nausea and vomiting and weakness.
She has been unable to keep any food, liquids or medications
down. The symptoms began 3 days ago and have not responded
to ibuprofen, acetaminophen, or Nyquil when she tried to take
them. The temperature has reached as high as 102˚F.
Allergies: none known to drugs or food or environmental
Medications-20 mg prednisone po qd, omeprazole 10 po qam
PMH-significant for 20-year history of steroid dependent
rheumatoid arthritis (RA). GERD. No other significant illnesses
or surgeries.
Social-denies alcohol, illicit drugs, vaping, tobacco use
Physical exam

5. Thin, ill appearing woman who is sitting in exam room chair as
she said she was too weak to climb on the exam table. VS Temp
101.2˚F, BP 98/64, pulse 110, Resp 16, PaO2 96% on room air.
ROS negative other than GI symptoms.
Based on the patient’s clinical presentation, the APRN
diagnoses the patient as having secondary hypocortisolism due
to the lack of prednisone the patient was taking for her RA
secondary to vomiting.
Question:
Explain why the patient exhibited these symptoms?
QUESTION 3
1. A 64-year-old Caucasian female presents to the clinic with
vague symptoms of non- specific abdominal pain, myalgias,
constipation, polyuria, and says she feels “fuzzy headed” much
of the time. She had about of kidney stones a few weeks ago and
she fortunately was able to pass the small stones without
requiring lithotripsy or other interventions. She was told by the
urologist to follow up with her primary care provider after the
kidney stones has resolved.
The APRN examining the patient orders a Chem 7 which
revealed a serum Ca++ of 13.1 mg/dl. The APN believes the
patient has primary hyperparathyroidism and refers the patient
to an endocrinologist who does a complete work up and concurs
with the APRN’s diagnosis.
Question:
What is the role of parathyroid hormone in the development of

6. primary hyperparathyroidism?
QUESTION 4
1. A 64-year-old Caucasian female presents to the clinic with
vague symptoms of non- specific abdominal pain, myalgias,
constipation, polyuria, and says she feels “fuzzy headed” much
of the time. She had a fracture of her right metatarsal without
trauma and currently is wearing a walking boot. She also had a
bout of kidney stones a few weeks ago and she fortunately was
able to pass the small stones without requiring lithotripsy or
other interventions. She was told by the urologist to follow up
with her primary care provider after the kidney stones has
resolved.
The APRN examining the patient orders a Chem 12 which
revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the
patient has primary hyperparathyroidism and refers the patient
to an endocrinologist who does a complete work up and concurs
with the APRN’s diagnosis.
Question 1 of 2:
Explain the processes involved in the formation of renal stones
in patients with hyperparathyroidism.
QUESTION 5
1. A 64-year-old Caucasian female presents to the clinic with
vague symptoms of non- specific abdominal pain, myalgias,
constipation, polyuria, and says she feels “fuzzy headed” much
of the time. She had a fracture of her right metatarsal without
trauma and currently is wearing a walking boot. She also had a
bout of kidney stones a few weeks ago and she fortunately was
able to pass the small stones without requiring lithotripsy or
other interventions. She was told by the urologist to follow up

7. with her primary care provider after the kidney stones has
resolved.
The APRN examining the patient orders a Chem 12 which
revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the
patient has primary hyperparathyroidism and refers the patient
to an endocrinologist who does a complete work up and concurs
with the APRN’s diagnosis.
Question 2 of 2:
Explain how a patient with hyperparathyroidism is at risk for
bone fractures. 0.5 points
QUESTION 6
1. A 64-year-old Caucasian female who is 4 weeks status post
total parathyroidectomy with forearm gland insertion presents to
the general surgeon for her post-operative checkup. She states
that her mouth feels numb and she feels “tingly all over. The
surgeon suspects the patient has hypoparathyroidism secondary
to the parathyroidectomy with delayed vascularization of the
implanted gland. She orders a Chem 20 to determine what
electrolyte abnormalities may be present. The labs reveal a
serum Ca++ of 7.1 mg/dl (normal 8.5 mg/dl-10.5 mg/dl) and
phosphorous level of 5.6 mg/dl (normal 2.4-4.1 mg/dl).
Question:
What serious consequences of hypoparathyroidism occur and
why?
QUESTION 7
1. A 17-year-old boy is brought to the pediatrician’s office
by his parents who are concerned about their son’s weight loss

8. despite eating more, frequent urination, unquenchable thirst,
and fatigue that is interfering with his school/work activities.
He had been seemingly healthy until about 3 months ago when
his parents started noticing these symptoms but put these
symptoms down to his busy schedule including a part time job.
He admits to sleeping more and tires very easily. He denies any
other symptoms.
PMH-noncontributory. No surgeries or major medical problems.
Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar
diabetes problem” but parents unclear on the exact disease
process
Social-denies alcohol, tobacco or illicit drug use. Not sexually
active. Junior at local high school and works in a fast food store
after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician
makes a tentative diagnosis of Diabetes Mellitus type 1 and
refers the boy and his parents to an endocrinologist for further
work up and management plan.
Question 1 of 6:
The patient exhibited classic signs of Type 1 diabetes. Explain
the pathophysiology of “polydipsia.”
QUESTION 8
1. A 17-year-old boy is brought to the pediatrician’s office

9. by his parents who are concerned about their son’s weight loss
despite eating more, frequent urination, unquenchable thirst,
and fatigue that is interfering with his school/work activities.
He had been seemingly healthy until about 3 months ago when
his parents started noticing these symptoms but put these
symptoms down to his busy schedule including a part time job.
He admits to sleeping more and tires very easily. He denies any
other symptoms.
PMH-noncontributory. No surgeries or major medical problems.
Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar
diabetes problem” but parents unclear on the exact disease
process
Social-denies alcohol, tobacco or illicit drug use. Not sexually
active. Junior at local high school and works in a fast food store
after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician
makes a tentative diagnosis of Diabetes Mellitus type 1 and
refers the boy and his parents to an endocrinologist for further
work up and management plan.
Question 2 of 6:
The patient exhibited classic signs of Type 1 diabetes. Explain
the pathophysiology of “polyuria.”
QUESTION 9

10. 1. A 17-year-old boy is brought to the pediatrician’s office
by his parents who are concerned about their son’s weight loss
despite eating more, frequent urination, unquenchable thirst,
and fatigue that is interfering with his school/work activities.
He had been seemingly healthy until about 3 months ago when
his parents started noticing these symptoms but put these
symptoms down to his busy schedule including a part time job.
He admits to sleeping more and tires very easily. He denies any
other symptoms.
PMH-noncontributory. No surgeries or major medical problems.
Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar
diabetes problem” but parents unclear on the exact disease
process
Social-denies alcohol, tobacco or illicit drug use. Not sexually
active. Junior at local high school and works in a fast food store
after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician
makes a tentative diagnosis of Diabetes Mellitus type 1 and
refers the boy and his parents to an endocrinologist for further
work up and management plan.
Question 3 of 6:
The patient exhibited classic signs of Type 1 diabetes. Explain
the pathophysiology of “polyphagia.”
QUESTION 10

11. 1. A 17-year-old boy is brought to the pediatrician’s office
by his parents who are concerned about their son’s weight loss
despite eating more, frequent urination, unquenchable thirst,
and fatigue that is interfering with his school/work activities.
He had been seemingly healthy until about 3 months ago when
his parents started noticing these symptoms but put these
symptoms down to his busy schedule including a part time job.
He admits to sleeping more and tires very easily. He denies any
other symptoms.
PMH-noncontributory. No surgeries or major medical problems.
Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar
diabetes problem” but parents unclear on the exact disease
process
Social-denies alcohol, tobacco or illicit drug use. Not sexually
active. Junior at local high school and works in a fast food store
after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician
makes a tentative diagnosis of Diabetes Mellitus type 1 and
refers the boy and his parents to an endocrinologist for further
work up and management plan.
Question 4 of 6:
The patient exhibited classic signs of Type 1 diabetes. Explain
the pathophysiology of “weight loss.”

12. QUESTION 11
1. A 17-year-old boy is brought to the pediatrician’s office
by his parents who are concerned about their son’s weight loss
despite eating more, frequent urination, unquenchable thirst,
and fatigue that is interfering with his school/work activities.
He had been seemingly healthy until about 3 months ago when
his parents started noticing these symptoms but put these
symptoms down to his busy schedule including a part time job.
He admits to sleeping more and tires very easily. He denies any
other symptoms.
PMH-noncontributory. No surgeries or major medical problems.
Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar
diabetes problem” but parents unclear on the exact disease
process
Social-denies alcohol, tobacco or illicit drug use. Not sexually
active. Junior at local high school and works in a fast food store
after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician
makes a tentative diagnosis of Diabetes Mellitus type 1 and
refers the boy and his parents to an endocrinologist for further
work up and management plan.
Question 5 of 6:
The patient exhibited classic signs of Type 1 diabetes. Explain
the pathophysiology of “fatigue.”

13. QUESTION 12
1. A 17-year-old boy is brought to the pediatrician’s office
by his parents who are concerned about their son’s weight loss
despite eating more, frequent urination, unquenchable thirst,
and fatigue that is interfering with his school/work activities.
He had been seemingly healthy until about 3 months ago when
his parents started noticing these symptoms but put these
symptoms down to his busy schedule including a part time job.
He admits to sleeping more and tires very easily. He denies any
other symptoms.
PMH-noncontributory. No surgeries or major medical problems.
Usual colds and ear infections as a child
Allergies-none know
Family history- maternal uncle with “some kind of sugar
diabetes problem” but parents unclear on the exact disease
process
Social-denies alcohol, tobacco or illicit drug use. Not sexually
active. Junior at local high school and works in a fast food store
after school and on weekends.
Labs in office: random glucose 220 mg/dl.
Based on his symptoms and the glucose level, the pediatrician
makes a tentative diagnosis of Diabetes Mellitus type 1 and
refers the boy and his parents to an endocrinologist for further
work up and management plan.
Question 6 of 6:
How do genetics and environmental factors contribute to the

14. development of Type 1 diabetes?
QUESTION 13
1. A 17-year-old boy recently diagnosed with Type I diabetes
is brought to the pediatrician’s office by his parents with a chief
complaint of “having the flu”. His symptoms began 2 days ago,
and he has vomited several times and has not eaten very much.
He can’t remember if he took his prescribed insulin for several
days because he felt so sick. Random glucose in the office
reveals glucose 560 mg/dl and the pediatrician made
arrangements for the patient to be admitted to the hospitalist
service with an endocrinology consult.
BP 124/80mmHg; HR 122bpm; Respirations 32 breaths/min;
Temp 97.2˚F; PaO297% on RA
Admission labs: Hgb 14.6 g/dl; Hct 58%
CMP- Na+ 122mmol/L; K+ 5.3mmol/L; Glucose 560mg/dl;
BUN 52mg/dl; Creatinine 4.9mg/dl;
Cl- 95mmol/L; Ca++ 8.8mmol/L; AST (SGOT) 248U/L; ALT
198U/L; CK 34/35 IU/L; Cholesterol 198mg/dl;
Phosphorus 6.8mg/dl; Acetone Moderate; LDH38U/L; Alkaline
Phosphatase 132U/L.
Arterial blood gas values were as follows: pH 7.09; Paco220mm
Hg; Po2100mm Hg; Sao2 98% (room air)
HCO3-7.5mmol/L; anion gap 19.4
A diagnosis of diabetic ketoacidosis was made, and the patient
was transferred to the Intensive Care Unit (ICU) for close
monitoring.

15. Question:
The hormones involved in intermediary metabolism, exclusive
of insulin, that can participate in the development of diabetic
ketoacidosis (DKA) are epinephrine, glucagon, cortisol, growth
hormone. Describe how they participate in the development of
DKA. 1 points
QUESTION 14
1. A 67-year-old African American male presents to the
clinic with a chief complaint that he has to “go to the bathroom
all the time and I feel really weak.” He states that this has been
going on for about 3 days but couldn’t come to the clinic sooner
as he went to the Wound Care clinic for a dressing change to his
right great toe that has been chronically infected, and he now
has osteomyelitis. Patient with known Type II diabetes with
poor control. His last HgA1C was 10.2 %. He says he can’t
afford the insulin he was prescribed and only takes half of the
oral agent he was prescribed. Random glucose in the office
revealed glucose of 890 mg/dl. He was immediately referred to
the ED by the APRN for evaluation of suspected hyperosmolar
hyperglycemic non ketotic syndrome (HHNKS). Also called
hyperglycemic hyperosmolar state (HHS).
Question:
Explain the underlying processes that lead to HHNKS or HHS.
QUESTION 15
1. A 32-year-old woman presented to the clinic complaining
of weight gain, swelling in her legs and ankles and a puffy face.
She also recently developed hypertension and diabetes type 2.
She noted poor short-term memory, irritability, excess hair

16. growth (women), red-ruddy face, extra fat around her neck,
fatigue, poor concentration, and menstrual irregularity in
addition to muscle weakness. Given her physical appearance
and history, a tentative diagnosis of hypercortical function was
made. Diagnostics included serum and urinary cortisol and
serum adrenocorticotropic hormone (ACTH). MRI revealed a
pituitary adenoma.
Question:
How would you differentiate Cushing’s disease from Cushing’s
syndrome?
QUESTION 16
1. A 47-year-old female is referred to the endocrinologist for
evaluation of her chronically elevated blood pressure,
hypokalemia, and hypervolemia. The patient’s hypertension has
been refractory to the usual medications such as beta blockers,
diuretics, and angiotensin-converting enzyme (ACE) inhibitors.
After a full work up including serum and urinary electrolyte
levels, aldosterone suppression test, plasma aldosterone to renin
ratio, and MRI which revealed an autonomous adenoma, the
endocrinologist diagnoses the patient with primary hyper-
aldosteronism.
Question:
What is the pathogenesis of primary hyper-aldosteronism?
QUESTION 17
1. A 47-year-old African American male presents to the
clinic with chief complaints of polyuria, polydipsia, polyphagia,
and weight loss. He also said that his vison occasionally blurs
and that his feet sometimes feel numb. He has increased hunger

17. despite weight loss and admits to feeling unusually tired. He
also complains of “swelling” and enlargement of his abdomen.
Past Medical History (PMH) significant for HTN fairly well
controlled with and ACE inhibitor; central obesity, and
dyslipidemia treated with a statin, Review of systems negative
except for chief complaint. Physical exam unremarkable except
for decreased filament test both feet. Random glucose in office
290 mg/dl. The APRN diagnoses the patient with type II DM
and prescribes oral medication to control the glucose level and
also referred the patient to a dietician for dietary teaching.
Question:
What is the basic underlying pathophysiology of Type II DM?
QUESTION 18
1. A 21-year-old male was involved in a motorcycle accident
and sustained a closed head injury. He is waking up and
interacting with his family and medical team. He complained of
thirst that doesn’t seem to go away no matter how much water
he drinks. The nurses note that he has had 3500 cc of pale-
yellow urine in the last 24 hours. Urine was sent for osmolality
which was reported as 122 mOsm/L. A diagnosis of probable
neurogenic diabetes insipidus was made.
Question:
What causes diabetes insipidus (DI)?
QUESTION 19
1. A 43-year-old female patient presents to the clinic with
complaints of nervousness, racing heartbeat, anxiety, increased
perspiration, heat intolerance, hyperactivity and palpitations.

18. She states she had had the symptoms for several months but
attributed the symptoms to beginning to care for her elderly
mother who has Alzheimer’s Disease. She has lost 15 pounds in
the last 3 months without dieting. Her past medical history is
significant for rheumatoid arthritis that she has had for the last
10 years well controlled with methotrexate and prednisone.
Physical exam is remarkable for periorbital edema, warm silky
feeling skin, and palpable thyroid nodules in both lobes of the
thyroid. Pending laboratory diagnostics, the APRN diagnoses
the patient as having hyperthyroidism, also called Graves’
Disease.
Question:
Explain how the negative feedback loop controls thyroid levels.
QUESTION 20
1. A 43-year-old female patient with known Graves’ Disease
presents to the clinic with complaints of nervousness, racing
heartbeat, anxiety, increased perspiration, heat intolerance,
hyperactivity and severe palpitations. She states she had been
given a prescription for propylthiouracil, an antithyroid
medication but she did not fill the prescription as she claims she
lost it. She had been given the option of thyroidectomy which
she declined. She also notes that she is having trouble with her
vision and often has blurry eyes. She states that her eyes seem
“to bug out of her face”. She has had recurrent outs of nausea
and vomiting. She was recently hospitalized for pneumonia.
Physical exam is significant for obvious exophthalmos and
pretibial myxedema. Vital signs are temp 101.2˚F, HR 138 and
irregular, BP 160/60 mmHg. Respirations 24. Electrocardiogram
revealed atrial fibrillation with rapid ventricular response. The
APRN recognizes the patient is experiencing symptoms of
thyrotoxic crisis, also called thyroid storm. The patient was

19. immediately transported to a hospital for critical care
management.
Question:
How did the patient develop thyroid storm? What were the
patient factors that lead to the development of thyroid storm?
QUESTION 21
1. A 44-year-old woman presents to the clinic with
complaints of extreme fatigue, weight gain, decreased appetite,
cold intolerance, dry skin, hair loss, and sleepiness. She also
admits that she often bursts into tears without any reason and
has been exceptionally forgetful. Her vision is occasionally
blurry, and she admits to being depressed without any social or
occupational triggers. Past medical history noncontributory.
Physical exam Temp 96.2˚F, pulse 62 and regular, BP 108/90,
respirations. Dull facial expression with coarse facial features.
Periorbital puffiness noted. Based on the clinical history and
physical exam, and pending laboratory data, the ARNP
diagnoses the patient with hypothyroidism.
Question:
What causes hypothyroidism?
QUESTION 22
1. A 44-year-old woman is brought to the clinic by her
husband who says his wife has had some mental status changes
over the past few days. The patient had been previously
diagnosed with hypothyroidism and had been placed on thyroid
replacement therapy but had been lost to follow-up due to
moving to another city for the husband’s work approximately 4
months ago. The patient states she lost the prescription bottle

20. during the move and didn’t bother to have the prescription filled
since she was feeling better. Physical exam revealed non-
pitting, boggy edema around her eyes, hands and feet as well as
the supraclavicular area. The APRN recognizes this patient had
severe myxedema and referred the patient to the hospital for
medical management.
Question:
What causes myxedema coma?
QUESTION 23
1. A 53-year-old woman presents to the primary care clinic
with complaints of severe headaches, palpitations, high blood
pressure and diaphoresis. She relates that these symptoms come
in clusters and when she has these “spells”, she also
experiences, tremor, nausea, weakness, anxiety, and a sense of
doom and dread, epigastric pain, and flank pain. She had one of
these spells when she was at the pharmacy and the pharmacist
took her blood pressure which was recorded as 200/118. The
pharmacist recommended that she immediately be evaluated for
these symptoms. Past medical history significant for a family
history of neurofibromatosis type 1 (NF1). Based on the
presenting symptoms and family history of NF1, the APRN
suspects the patient has a pheochromocytoma. Laboratory data
and computerized tomography of the abdomen confirms the
diagnosis.
Question 1 of 2:
What is a pheochromocytoma and how does it cause the classic
symptoms the patient presented with?
QUESTION 24

21. 1. A 53-year-old woman presents to the primary care clinic
with complaints of severe headaches, palpitations, high blood
pressure and diaphoresis. She relates that these symptoms come
in clusters and when she has these “spells”, she also
experiences, tremor, nausea, weakness, anxiety, and a sense of
doom and dread, epigastric pain, and flank pain. She had one of
these spells when she was at the pharmacy and the pharmacist
took her blood pressure which was recorded as 200/118. The
pharmacist recommended that she immediately be evaluated for
these symptoms. Past medical history significant for a family
history of neurofibromatosis type 1 (NF1). Based on the
presenting symptoms and family history of NF1, the APRN
suspects the patient has a pheochromocytoma. Laboratory data
and computerized tomography of the abdomen confirms the
diagnosis.
Question 2 of 2:
What are the treatment goals for managing pheochromocytoma?