ACE Self-Assessment Program (ASAP): Sample Questions

The ASAP online self-assessment tool provides learners with case-based questions and answers designed to challenge clinical thought processes in recall, interpretation, and problem-solving skills in the evaluation, diagnosis, treatment, and management of endocrine diseases.

ASAP features patient cases with case histories, images, lab results and other pertinent information. After completing each topic-based question set, participants are presented with rationales and references for further learning.

Learn more about ASAP and how it helps you meet your CME/MOC needs by clicking here .

ASAP Challenge: Pituitary

A 35 year-old female presents with a weight gain of about 15 lbs in the last two years. She complains of mild weakness in her muscles when she gets up from a chair. She also has irregular light menstrual periods and has noticed the appearance of a few coarse hairs on her chin in last six months. She has a history of type 2 diabetes, depression, and seizures. Her medications include metformin, phenytoin, and sitagliptin.

Physical examination is notable for blood pressure (BP) of 140/90 mm Hg, a body mass index (BMI) of 34.1 kg/m2 (normal, 18.5 to 24.9 kg/m2), and central obesity. She has mild hirsutism on her chin, acanthosis nigricans on the nape of her neck, a small dorsocervical hump, abdominal striae, and a few ecchymoses.

Laboratory data were as follows:

Fasting glucose: 150 mg/dL (normal, 70-99 mg/dL)

Sodium (Na): 140 mmol/L (normal, 133-145 mmol/L)

Potassium (K): 3.4 mmol/L (normal, 3.5-5.5 mmol/L)

Thyroid-stimulating hormone (TSH): 0.50 µIU/mL (normal, 0.34-4.5 µIU/mL)

Total testosterone: 20 ng/dL (normal, 2-45 ng/dL)

17-Hydroxyprogesterone: 50 ng/dL (normal,

DHEA-sulfate: 230 µg/dL (normal, 18-391 µg/dL)

A 24-urine free cortisol (UFC) was 40 µg/24 hr (normal,

ASAP Challenge: Hypoglycemia

A 42-year-old woman is referred to you for evaluation. She has symptoms of hypoglycemia in both the fasting and postprandial period. She presents with documented hyperinsulinemic hypoglycemia. The following laboratory test results were obtained during an episode where the patient was diaphoretic and confused:

Glucose: 39 mg/dL (normal, 70-140 mg/dL)

C-peptide: 3.3 ng/mL (normal, 1.1-4.4 ng/mL)

Insulin: 10 µIU/mL (normal, 2.6-24.9 µU/mL)

Hypoglycemia agent screen (including repaglinide and glimepiride): negative

The patient has no further notable medical history and has had no prior surgery. Additionally, she has regular menstrual cycles, and her serum calcium is normal. The rest of the evaluation was normal. A triphasic computerized tomography (CT) scan of the abdomen and endoscopic ultrasonography are both normal. After consulting with an endocrine surgeon, you are asked to order a selective arterial calcium stimulation test (SACST) to regionalize the presumed insulinoma. The concentrations of insulin in the hepatic venous blood after intra-arterial calcium stimulation were as follows:

Hepatic Vein Insulin (µU/mL) upon injection of calcium in the following arteries:
Time (seconds) *Gastroduodenal Artery *Superior Mesenteric Artery *Splenic Artery
Baseline 212 33 31
20 198 32 32
40 178 30 180
60 166 6 556

*Insulin values are measured in blood sampled from the hepatic vein after intra-arterial injection of calcium into the respective arteries (arterial territories) supplying the pancreas.

ASAP Challenge: Nutrition

A 45 year-old female who is “health conscious” came to your clinic for advice about healthy eating and lifestyle. She is an editor of a shopping magazine and frequently reads articles about diets, nutrients, supplements, and healthy lifestyles. She found that much of the information she recently read is contradictory, which made her confused about what to eat and do. Her mother had type 2 diabetes and died at age 61 from a fatal myocardial infarction. The death of her mother at such young age compelled her to eat healthier and to walk for 30 minutes most days of the week. She is now eating three regular meals per day and does not eat snacks. She tries to read all of her food labels and to keep her food intake to 1,800 calories per day. Although she dines out approximately 5 days per week, she controls her food portions as much as she can. She has maintained her weight for the last 5 years. She likes good wine and drinks 1-2 glasses when she dines out. She takes several over-the-counter supplements including vitamin D, calcium, magnesium, vitamin B12, and cinnamon. She does not have any gastro-intestinal symptoms, and she sleeps 6-7 hours every night.

  • Weight: 172 lbs
  • Body mass index (BMI): 28 kg/m2 (normal, 18.5 to 24.9 kg/m2)
  • Waist circumference is 32 inches
  • Blood pressure: 124/72 mm Hg
  • Serum low density lipoprotein cholesterol (LDL-C): 122 mg/dL (desirable, <100 mg/dL)
  • Serum high density lipoprotein cholesterol (HDL-C): 39 mg/dL (desirable, ≥60 mg/dL)
  • Serum triglycerides (TG): 280 mg/dL (desirable, <150 mg/dL)
  • Fasting plasma glucose: 92 mg/dL (normal, 70-100 mg/dL)
  • Glycated hemoglobin (HbA1c): 5.6% (normal, <5.7%)

She told you that she would like to follow a strict vegetarian dietary pattern since she heard that it is the best lifestyle. She would also like to follow a gluten-free diet to shed few pounds.

ASAP Challenge: Pediatrics

James is 5 years old and has had worsening headaches for several weeks. He awakens with repeated vomiting. His parents rush him to the emergency room where he has a generalized seizure. A computerized tomography (CT) scan shows a posterior fossa tumor and hydrocephalus. He is admitted to the hospital and an emergency ventriculo-peritoneal shunt is placed. Magnetic resonance imaging (MRI) confirms a likely medulloblastoma. In discussion with oncology, parents ask about future effects of treatment for the tumor.

ASAP Challenge: Reproductive

A 52 year-old female presents with multiple complaints that she feels are due to menopause and would like her “hormone levels” checked. She complains of hot flashes, vaginal dryness, decreased libido, and weight gain. The hot flashes are severe. They keep her up at night and often disrupt her work during the day, especially when they occur during meetings with colleagues. She asks about treatment with hormone replacement therapy.

The patient smokes ½ pack of cigarettes daily. She is currently being treated for hypertension. Her blood pressure is well controlled with a diuretic, and she has no history of thromboembolic disease. She had a hysterectomy at age 45 for abnormal uterine bleeding due to fibroids. A recent mammogram and breast ultrasound were normal, and a recent DXA (dual energy X-ray absorptiometry) scan shows normal bone density at the hip and spine.

Family history is remarkable for breast cancer in her mother, diagnosed at age 60 years. Her mother is now age 75 years with dementia. Her father had a myocardial infarction at age 50 years.

On laboratory testing, her follicle-stimulating hormone (FSH) is 95 mIU/mL (normal postmenopausal, 16.7-113.6 IU/L), and her estradiol is <20 pg/mL (normal postmenopausal, <10 pg/mL).

ASAP Challenge: Thyroid

You are asked by your pulmonary colleague to evaluate a 67 year-old man with hypertension and hyperlipidemia who has developed progressive shortness of breath over the past 6 months. He often wakes up at night and has a feeling of choking. He has shortness of breath when he climbs stairs. When he moves his arm above his head, he feels unwell and develops difficulty in breathing. He does not have any difficulty swallowing. He denies heat or cold intolerance, diarrhea, constipation, tremors, palpitations, or recent weight changes. He has a remote history of childhood asthma, but has not had any episodes since he became an adult. His medication includes losartan 100 mg once per day and simvastatin 20 mg once per day. His mother has a history of goiter and had thyroid surgery years ago.

On physical examination, his body mass index (BMI) is 27.7 kg/m2 (normal, 18.5 to 24.9 kg/m2). His blood pressure is 128/80 mm Hg, and his pulse rate is 82 beats/minute. He has a minimally enlarged goiter with an uneven nodular surface. You could not feel the lower border of the thyroid when he extends his neck. No bruit or tenderness is observed. When he moves his arm above his head, his face turns red and he starts to have shortness of breath. No enlarged neck lymph nodes are palpated. Otherwise, his physical examination is unremarkable.

His laboratory test results are as follows: Serum thyroid-stimulating hormone (TSH): 0.15 mIU/L (reference range, 0.27-4.2 mIU/L) Serum free thyroxine (T4): 1.5 ng/dL (reference range, 0.93-1.7 ng/dL)

His chest x-ray shows deviated trachea to the right. A computerized tomography (CT) scan of the neck without contrast shows a 6x8 cm substernal multinodular goiter surrounding and causing narrowing of the trachea. His radioactive iodine uptake is 28% (normal, 8-25%), and scan shows areas of increased and decreased uptake.

ASAP Challenge: Hypertension

A 45 year-old Caucasian woman presents to your office for a health physical. She has a family history of heart disease. Her father had a myocardial infarction (MI) at age 60. She does not smoke. She works at a local bank as a manager and is often stressed with work and her two kids. She tries to exercise regularly by going for a walk with her family, but admits she does not always succeed. She and her husband each have two glasses of wine after dinner regularly. She tries to watch her diet by limiting her saturated fat intake. Upon physical examination, her blood pressure (BP) is 138/87 mm Hg; her weight is 72 kg, and her body mass index (BMI) is 28 kg/m2 (normal, 18.5 to 24.9 kg/m2). No edema or murmur is noted. She does not have an abdominal bruit. Her laboratory work up shows normal range electrolytes. Her creatinine is 0.9 mg/dL (normal, 0.84-1.21 mg/dL), and her low density lipoprotein cholesterol (LDL-C) is 149 mg/dL (desirable, <100 mg/dL). Her BP was 134/86 mm Hg one year ago, according to her chart.

ASAP Challenge: Bone

A 76 year-old woman is referred for evaluation of multiple non-traumatic vertebral compression fractures developing over the past year. She was initially diagnosed with osteoporosis at age 58 years, with her lowest T-score of -3.2 at her lumbar spine. She was treated with alendronate for one year, but because of significant gastroesophageal irritation, she switched to intravenous zoledronic acid once a year for the next three years without symptoms, followed by a 6-year drug holiday. Once her bone density began to decrease after 6 years off treatment, she received a second three-year course of intravenous zoledronic acid, again without symptoms.  After completing her second course of zoledronic acid, her bone density did not increase as much as it did with her first course, and her primary care physician switched her to denosumab 60 mg subcutaneously every six months. Because her bone density increased significantly after four years of denosumab treatment, her physician discontinued denosumab. One year after her last dose of denosumab, she developed severe back pain without a fall or other injury, and her spine films showed new vertebral compression fractures at L1, L3, and L4.

ASAP Challenge: Diabetes

A 21 year-old man with a 7-year history of type 2 diabetes mellitus (T2DM) presents for follow-up. He was diagnosed with T2DM at age 14 years. At that time, his body mass index (BMI) was in the 99th percentile for his age. His mother has a history of gestational diabetes mellitus during her pregnancy with him and was diagnosed with T2DM in her early forties, when he was ten years old. His current BMI is 41 kg/m2 (normal, 18.5 to 24.9 kg/m2). He has been treated with metformin and insulin analogues, but he has not been taking the insulin recently because he feels unwell after he exercises with symptoms of shakiness, sweatiness, and hunger. His glycated hemoglobin (HbA1c) is 9.2% (normal, <5.7%). He wants to know more about diabetes mellitus and asks if there are other medication options for him.