Identify the function of the sternocleidomastoid muscle.    

These statements about creatine phosphateare true except:

Diabetes Mellitus Type 1 (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition: Autoimmune destruction of pancreatic β-cells → absolute insulin deficiency. Pathophysiology: T-cell–mediated autoimmune attack on islet cells (especially HLA-DR3/DR4 associations). Leads to complete loss of endogenous insulin production. Onset often in childhood or adolescence but can occur at any age (“LADA” in adults). Epidemiology: Peaks at 4–6 years and 10–14 years. ~5–10% of diabetes cases in the U.S. Increased risk with family history or other autoimmune diseases (thyroiditis, celiac disease). Key Mechanism: Autoantibodies (e.g., anti-GAD65, IA-2, insulin autoantibodies) precede hyperglycemia. 2. History Typical Symptoms (Classic Triad): Polyuria, polydipsia, polyphagia. Weight loss despite normal/increased appetite. Fatigue, blurred vision. Acute Presentation: Diabetic ketoacidosis (DKA): nausea, vomiting, abdominal pain, rapid breathing, fruity breath. Risk Factors/Associations: Family history of autoimmune disease. Viral triggers (e.g., coxsackievirus). Historical Clues: Sudden symptom onset over days to weeks. No history of obesity or metabolic syndrome features. 3. Exam Findings General: Thin or underweight body habitus. Dehydration signs: dry mucous membranes, poor skin turgor. DKA Findings: Kussmaul respirations (deep, labored breathing). Fruity (acetone) odor on breath. Hypotension, tachycardia. Altered mental status in severe cases. Associated Autoimmune Conditions: Goiter (thyroid disease), vitiligo, celiac signs. 4. Making the Diagnosis Key Laboratory Findings: Fasting plasma glucose ≥126 mg/dL on two occasions. Random glucose ≥200 mg/dL with classic symptoms. A1C ≥6.5%. Oral glucose tolerance test (OGTT): 2-hour value ≥200 mg/dL. Autoimmune Markers: Positive GAD65, IA-2, insulin autoantibodies, or ZnT8 confirm autoimmune etiology. Additional Testing: Low or undetectable C-peptide (reflects lack of insulin production). Urine ketones positive in DKA or poor control. Gold Standard: Demonstration of autoimmune β-cell destruction with positive diabetes-associated autoantibodies. Distinguishing from Type 2 DM: Younger, leaner, rapid onset, ketosis-prone, autoimmune antibodies present. 5. Management (Exam Concepts) General Principles: Lifelong exogenous insulin therapy is required. Frequent glucose monitoring (SMBG or CGM). Goal A1C: generally

Pheochromocytoma (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:A catecholamine-secreting tumor arising from chromaffin cells of the adrenal medulla (or extra-adrenal paraganglia, termed paraganglioma).Secretes epinephrine, norepinephrine, and/or dopamine, leading to episodic or sustained sympathetic overactivity. Pathophysiology: Excess catecholamines → overstimulation of α- and β-adrenergic receptors. Results in vasoconstriction, tachycardia, hyperglycemia, and hypertension. Catecholamine surges may be triggered by stress, surgery, exercise, or certain drugs (e.g., β-blockers before α-blockade). Rule of 10s (Classic Teaching): 10% bilateral 10% extra-adrenal (paragangliomas) 10% malignant 10% in children(Recent data: up to 30–40% associated with germline mutations.) Genetic Associations: MEN 2A/2B (RET mutation) Von Hippel–Lindau (VHL) disease Neurofibromatosis type 1 (NF1) Succinate dehydrogenase (SDH) gene mutations Epidemiology: Rare, accounting for

Hypoparathyroidism (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:A disorder characterized by deficient secretion or action of parathyroid hormone (PTH), leading to hypocalcemia and hyperphosphatemia. Pathophysiology: ↓ PTH → ↓ bone resorption of calcium, ↓ renal calcium reabsorption, ↓ activation of vitamin D → ↓ intestinal calcium absorption. Simultaneous ↑ renal phosphate reabsorption → hyperphosphatemia. Major Causes: Postsurgical (most common): accidental removal or damage to parathyroid glands during thyroid, parathyroid, or neck surgery. Autoimmune destruction: part of autoimmune polyglandular syndrome type I. Congenital: DiGeorge syndrome (22q11 deletion → absent parathyroids). Infiltrative/metabolic: hemochromatosis, Wilson disease, severe hypomagnesemia (impairs PTH secretion). Idiopathic or genetic PTH resistance: pseudohypoparathyroidism (high PTH, hypocalcemia due to end-organ resistance). Epidemiology: Uncommon; most cases are iatrogenic (post-thyroidectomy). 2. History Symptoms (due to hypocalcemia): Neuromuscular irritability: perioral or fingertip tingling, muscle cramps, carpopedal spasms. Tetany: involuntary muscle contractions, laryngospasm, or seizures in severe cases. Psychiatric: anxiety, irritability, depression. Chronic manifestations: dry skin, brittle nails, coarse hair, cataracts, dental abnormalities. Historical Clues: Recent neck or thyroid surgery. Autoimmune history (e.g., mucocutaneous candidiasis, adrenal insufficiency). Family history of congenital syndromes. 3. Exam Findings Neuromuscular Signs (classic for hypocalcemia): Chvostek sign: facial muscle contraction when tapping facial nerve (cheek). Trousseau sign: carpal spasm after inflation of BP cuff for 3 min. Cardiovascular: Hypotension, prolonged QT interval on ECG. Skin/Hair: Dry, flaky skin; brittle nails; coarse hair. Eyes: Cataracts (chronic hypocalcemia). Dentition: Enamel hypoplasia, defective root formation (pediatric cases). 4. Making the Diagnosis Key Lab Pattern (Primary Hypoparathyroidism): ↓ Serum calcium ↑ Serum phosphate ↓ or inappropriately normal PTH Normal or low magnesium (severe Mg deficiency suppresses PTH). Confirmatory Tests: Serum magnesium: to exclude Mg deficiency. Urinary calcium: may be low. Vitamin D levels: rule out deficiency. ECG: may show prolonged QT interval. If postsurgical: diagnosis is clinical (neck surgery + low calcium + low PTH).If autoimmune/genetic: test for associated antibodies or genetic deletions. Gold Standard: Low PTH with concurrent hypocalcemia and hyperphosphatemia. 5. Management (Exam Concepts) (Conceptual overview only—no dosing or treatment regimens.) Acute Hypocalcemic Crisis (Tetany/Seizure): IV calcium administration under cardiac monitoring. Chronic Management: Oral calcium supplements and activated vitamin D analogs (calcitriol) to maintain normal calcium and phosphate balance. Thiazide diuretics (conceptual) may reduce urinary calcium loss. Recombinant human PTH (rarely used): for refractory chronic cases. Correct hypomagnesemia before calcium replacement. Postsurgical Prevention: Preserve parathyroid glands during thyroidectomy. Prophylactic calcium and vitamin D in high-risk surgical patients. Exam Tips: Low Ca²⁺, high phosphate, low PTH = primary hypoparathyroidism. Low Ca²⁺, high phosphate, high PTH = pseudohypoparathyroidism (PTH resistance). Prolonged QT interval on ECG is a key clue. Most common cause = neck surgery. NBME-Style Practice Question A 46-year-old woman presents with muscle cramps and tingling around her mouth one week after total thyroidectomy. Physical exam shows facial muscle twitching when the facial nerve is tapped. Labs show: Calcium: 7.0 mg/dL (low) Phosphate: 5.8 mg/dL (high) PTH: low Which of the following is the most likely diagnosis? A. Primary hypoparathyroidismB. Secondary hyperparathyroidismC. PseudohypoparathyroidismD. Vitamin D deficiency

Gigantism (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:Gigantism is excessive growth hormone (GH) secretion before epiphyseal plate closure in children/adolescents, leading to abnormally accelerated linear growth and tall stature.After epiphyseal fusion, the same process manifests as acromegaly. Pathophysiology: GH excess → ↑ hepatic IGF-1, promoting growth of bone, cartilage, and soft tissues. Because epiphyseal plates remain open, longitudinal bone growth increases dramatically. Excess GH/IGF-1 also causes organomegaly, metabolic dysfunction, and pituitary mass effects. Etiology: Pituitary somatotroph adenoma (most common). Rare: ectopic GHRH-producing tumors (pancreatic, bronchial). Genetic syndromes: McCune–Albright, Carney complex, MEN 1. Epidemiology: Very rare; typically presents in adolescence. 2. History Key Presentation: Rapid growth velocity above expected percentiles. Extreme height compared with peers or family norms. Associated Symptoms: Headaches, visual changes (bitemporal hemianopsia) from pituitary mass. Excessive sweating, fatigue, heat intolerance. Joint pain, rapid shoe and clothing size changes. Metabolic: weight gain, insulin resistance, possible diabetes. Reproductive: delayed puberty, menstrual irregularities. Organ/System Effects: Enlargement of hands, feet, facial features (may resemble acromegaly features). Cardiomegaly, sleep apnea. Historical Clues: Growth acceleration charted on pediatric growth curves. Symptoms of pituitary mass (headache, visual deficits). 3. Exam Findings Growth/Anthropometrics: Tall stature with accelerated growth velocity. Arm span often exceeds height. Craniofacial Features: Frontal bossing, prognathism (jaw protrusion), nasal enlargement. Spaced teeth, macroglossia. Musculoskeletal: Large hands/feet, joint laxity or pain. Neurologic: Visual field defects (classically bitemporal hemianopsia). Skin: Oily skin, acne, skin tags. Cardiovascular: Hypertension, signs of cardiomyopathy in advanced cases. 4. Making the Diagnosis Step 1 – Screening: Serum IGF-1: elevated; most reliable initial test (stable marker of GH activity). Step 2 – Confirmatory Testing: Oral glucose tolerance test (OGTT) with GH measurement: Normal response: glucose suppresses GH. Gigantism: GH fails to suppress after glucose load. Step 3 – Identify Source: MRI of the pituitary gland: Detects pituitary adenoma (micro or macroadenoma). If MRI negative → evaluate for ectopic GHRH via serum GHRH level; CT/MRI of chest/abdomen. Additional Labs: Fasting glucose/insulin (insulin resistance). Other pituitary hormones (possible compression effects). Gold Standard: Elevated IGF-1 + failure of GH suppression on OGTT + pituitary adenoma on MRI. 5. Management (Exam Concepts) (Conceptual overview only—no dosing or treatment regimens.) 1. First-Line Therapy Transsphenoidal resection of pituitary adenoma. 2. Medical Therapy Somatostatin analogs (octreotide, lanreotide) — suppress GH secretion. GH receptor antagonist (pegvisomant) — blocks IGF-1 production. Dopamine agonists (cabergoline) — used in some GH/prolactin co-secreting tumors. 3. Radiation Therapy For residual tumor or persistent disease not controlled with surgery/medications. 4. Long-Term Monitoring Serial IGF-1 measurements. Periodic pituitary imaging. Screen for cardiomyopathy, sleep apnea, and metabolic complications.   QUESTION NBME-Style Practice Question A 14-year-old boy is brought to clinic for rapid growth over the past year. His height increased from the 75th to >99th percentile. He reports headaches and needing larger shoes every few months. Exam shows frontal bossing, enlarged hands, and visual field deficits. Labs reveal markedly elevated IGF-1. After an oral glucose load, GH levels remain high. Which of the following is the most appropriate next step to determine the underlying cause? A. Serum GHRH levelB. MRI of the pituitary glandC. Bone age radiographD. Abdominal CT scan  

Vitamin D Deficiency (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:A condition characterized by inadequate vitamin D levels, resulting in impaired calcium and phosphate absorption, leading to secondary hyperparathyroidism, hypocalcemia, and bone demineralization. Physiology Recap: Vitamin D (cholecalciferol/ergocalciferol) is hydroxylated in the liver → 25-hydroxyvitamin D, then in the kidney → 1,25-dihydroxyvitamin D (calcitriol), the active form. Calcitriol promotes calcium and phosphate absorption in the intestine and reabsorption in the kidney, and stimulates bone mineralization. Pathophysiology: Deficiency → ↓ intestinal calcium absorption → hypocalcemia → compensatory ↑ PTH → secondary hyperparathyroidism. PTH increases bone resorption → osteomalacia (adults) or rickets (children). Causes: Inadequate intake or sunlight exposure (most common). Malabsorption (celiac disease, cystic fibrosis, bariatric surgery). Chronic kidney disease (↓ 1α-hydroxylation). Liver disease (↓ 25-hydroxylation). Medications: anticonvulsants (phenytoin, phenobarbital), glucocorticoids. Exclusive breastfeeding without supplementation in infants. Epidemiology: Common in elderly, limited sun exposure, darker skin pigmentation, and northern latitudes. 2. History Adults (Osteomalacia): Diffuse bone pain and tenderness. Muscle weakness (especially proximal). Fatigue and difficulty walking. Fractures after minimal trauma. Children (Rickets): Delayed growth, bone deformities (bowing of legs, rachitic rosary, frontal bossing). Delayed tooth eruption. Hypotonia and developmental delay (in severe cases). Historical Clues: Minimal sun exposure, low dietary intake, malabsorptive conditions, chronic kidney or liver disease, anticonvulsant use. 3. Exam Findings Adults: Bone tenderness (especially ribs, sternum, long bones). Waddling gait or difficulty rising from chair. Muscle weakness (proximal). Children: Skeletal deformities: Bowed legs (genu varum). Rachitic rosary (costochondral bead-like enlargements). Craniotabes (soft skull). Delayed fontanelle closure. Other: Signs of hypocalcemia in severe cases (Chvostek or Trousseau signs). 4. Making the Diagnosis Laboratory Pattern: Parameter Finding Calcium ↓ or low-normal Phosphate ↓ PTH ↑ (secondary hyperparathyroidism) Alkaline phosphatase ↑ (bone turnover) 25-hydroxyvitamin D (25[OH]D) ↓ (best screening test) Key Diagnostic Points: 25(OH)D < 20 ng/mL = deficiency; 20–30 = insufficiency. 1,25(OH)₂D (calcitriol) is not a good screening test — may be normal or high in early deficiency. X-rays (if bone pain/deformities): Osteopenia, Looser zones (pseudofractures), or bone bowing in children. Bone biopsy (rare): confirms osteoid accumulation (unmineralized bone). Gold Standard: Low 25-hydroxyvitamin D level with corresponding biochemical abnormalities (↑ PTH, ↓ calcium, ↓ phosphate, ↑ ALP). 5. Management (Exam Concepts) (Conceptual overview only—no dosing or treatment regimens.) General Principles: Correct vitamin D deficiency and address calcium intake. Identify and treat underlying causes (malabsorption, CKD, liver disease). Supplementation (Conceptual): Vitamin D2 (ergocalciferol) or D3 (cholecalciferol) replacement. Calcium supplementation to restore balance. Activated vitamin D (calcitriol) in chronic kidney disease (impaired conversion). Lifestyle Measures: Encourage adequate sunlight exposure (10–15 min several times/week). Balanced diet with fortified foods (milk, fish oils, eggs). Monitoring: Recheck calcium, phosphate, ALP, and 25(OH)D levels after therapy. Watch for hypercalcemia during high-dose replacement. NBME-Style Practice Question A 62-year-old woman presents with progressive muscle weakness and diffuse bone pain. She spends most of her time indoors and has a diet low in dairy. Labs show: Calcium: 8.0 mg/dL (low) Phosphate: 2.0 mg/dL (low) Alkaline phosphatase: elevated PTH: elevated 25-hydroxyvitamin D: low Which of the following is the most likely diagnosis? A. Primary hyperparathyroidismB. Osteomalacia due to vitamin D deficiencyC. Paget disease of boneD. Osteoporosis

Paget Disease of Bone (Osteitis Deformans) (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:Chronic skeletal disorder caused by disorganized bone remodeling—excessive bone resorption followed by chaotic bone formation—resulting in enlarged, deformed, and weak bone. Pathophysiology: Overactive osteoclasts → excessive bone breakdown. Compensatory osteoblastic activity → disorganized, sclerotic new bone (mosaic pattern). Affected bone is hypervascular, structurally weak, and prone to fractures. Commonly involves pelvis, skull, spine, femur, tibia. Etiology: Unknown; likely genetic (SQSTM1 mutations) or viral (paramyxovirus) triggers. Epidemiology: Onset usually after age 50, more common in men. Higher prevalence in European descent. Often asymptomatic, discovered incidentally via elevated alkaline phosphatase (ALP). 2. History Asymptomatic in up to 80%. Symptomatic findings: Bone pain (most common symptom; dull, aching, worse at night). Skeletal deformities: Skull enlargement (“increasing hat size”), frontal bossing. Bowing of long bones (femur, tibia). Hearing loss (CN VIII compression from skull involvement). Fractures: transverse (“chalk-stick”) fractures in long bones. Warmth over affected bone (due to increased vascularity). Complications: Osteoarthritis (bone deformity near joints). High-output heart failure (rare, from increased vascularity). Osteosarcoma (rare malignant transformation). Historical Clues: Older adult with bone pain + elevated ALP + normal calcium. Hearing loss or increasing hat size = classic clue. 3. Exam Findings General: Often normal; may show deformities or tenderness. Skull: Frontal bossing, craniofacial enlargement, hearing loss. Spine: Kyphosis or spinal stenosis (nerve compression). Extremities: Bowing of legs (anterolateral tibial curvature), increased warmth. CV: In advanced disease, signs of high-output cardiac failure. 4. Making the Diagnosis Laboratory Findings: Test Result Alkaline phosphatase (ALP) ↑↑ (high bone turnover) Calcium Normal Phosphate Normal PTH Normal Urinary hydroxyproline ↑ (bone collagen breakdown) Imaging: X-ray (diagnostic hallmark): Early: osteolytic (“blade of grass” or “flame-shaped”) lesions. Mixed phase: patchy sclerosis and cortical thickening. Late: dense, enlarged bone with deformity. Skull: “cotton wool” appearance. Bone scan: Increased uptake in affected bones—maps disease extent. Diagnostic Pattern: Elevated ALP with normal calcium and phosphate + characteristic radiologic findings. Gold Standard: X-ray evidence of mixed lytic–sclerotic lesions + elevated ALP. 5. Management (Exam Concepts) (Conceptual overview only—no dosing or treatment regimens.) 1. Asymptomatic Patients: Observation if no pain or deformity and ALP stable. 2. Symptomatic or Active Disease: First-line: Bisphosphonates (e.g., alendronate, zoledronic acid) → inhibit osteoclasts. Second-line: Calcitonin (less potent, used if bisphosphonates contraindicated). Pain management: NSAIDs or acetaminophen for bone pain. Calcium and vitamin D supplementation to prevent hypocalcemia during treatment. 3. Complications Management: Orthopedic surgery: for fractures, severe deformity, or arthritis. Hearing aids for auditory loss. Monitor ALP levels for treatment response and recurrence.   QUESTION A 72-year-old man presents to his primary care clinic with a complaint of increasing right hip discomfort over the past few months. He denies recent trauma. His medical history includes hypertension and type 2 diabetes. He does not take corticosteroids. He reports difficulty hearing from his right ear and occasional headaches. Physical examination reveals mild anterior bowing of the right tibia and decreased range of motion in the right hip. Laboratory studies show: Serum calcium: 9.4 mg/dL (8.6–10.2) Phosphate: 3.1 mg/dL (2.5–4.5) Alkaline phosphatase: 430 U/L (40–129) PTH: 42 pg/mL (10–65) Which of the following is the most appropriate next step in management? A) Reassurance and observationB) Oral bisphosphonate therapyC) Serum 25-hydroxyvitamin D levelD) Total body bone scintigraphy  

Thyroid Cancer (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:Malignant tumors arising from thyroid follicular or parafollicular cells, varying from indolent to aggressive behavior. Epidemiology: Most common endocrine malignancy. Women > men; peak incidence 30–50 years. Excellent prognosis for differentiated cancers (papillary, follicular). Major Types (High-Yield): Type % Cell Origin Key Features Papillary carcinoma 80–85% Follicular cells Most common; lymphatic spread; prior radiation risk; excellent prognosis. Follicular carcinoma 10–15% Follicular cells Hematogenous spread (bone/lung); requires invasion for diagnosis. Medullary carcinoma 3–5% Parafollicular (C) cells Produces calcitonin; MEN 2A/2B association. Anaplastic carcinoma

Obesity (Study Outline) For study only—this is not medical advice or a substitute for professional care. 1. Background Definition:Obesity is a chronic, multifactorial condition characterized by excess adipose tissue leading to metabolic, mechanical, and cardiovascular complications. BMI 25–29.9 = overweight BMI ≥30 = obesity BMI ≥40 = severe obesity (class III) Pathophysiology: Energy imbalance: caloric intake > expenditure. Hormonal factors: Leptin resistance → impaired satiety. Insulin resistance → hyperinsulinemia and weight gain. Ghrelin ↑ → increased appetite. Genetic influences: MC4R mutations (common monogenic cause), polygenic risk. Environmental contributors: sedentary lifestyle, high-calorie diet, stress, sleep deprivation. Adipose tissue as an endocrine organ: Produces inflammatory cytokines → metabolic syndrome. Contributes to dyslipidemia, NAFLD, insulin resistance. Etiology: Behavioral/lifestyle factors High socioeconomic food access to calorie-dense foods Genetic predisposition Secondary causes (exam focus): Hypothyroidism Cushing syndrome Hypothalamic injury Medications: antipsychotics, insulin, sulfonylureas, steroids Epidemiology: Very common in the U.S.; affects all age groups. Strong correlation with cardiometabolic disease. 2. History Weight-related symptoms: Progressive weight gain, difficulty losing weight. Fatigue, joint pain (knees, back). Snoring or daytime somnolence (possible OSA). Metabolic symptoms: Polyuria/polydipsia (possible insulin resistance or T2DM). Dyspnea on exertion. Lifestyle clues: High caloric intake, low physical activity. Stress or sleep disorders affecting appetite regulation. Secondary cause clues: Cold intolerance, constipation (hypothyroidism). Striae, proximal weakness (Cushing syndrome). Hypothalamic injury history. 3. Exam Findings General: Elevated BMI, increased waist circumference (central adiposity). Cardiovascular: Hypertension, tachycardia. Respiratory: Signs of obstructive sleep apnea (large neck circumference). Dermatologic: Acanthosis nigricans (insulin resistance). Intertrigo or skin infections. Musculoskeletal: Joint tenderness, limited mobility. Endocrine clues: Violaceous striae or fat redistribution → possible Cushing syndrome. Thyroid enlargement or bradycardia → possible hypothyroidism. 4. Making the Diagnosis Primary Diagnosis: BMI-based classification on physical exam. Waist circumference: Men >40 in Women >35 in→ associated with ↑ cardiometabolic risk. Screening for Comorbidities (high-yield for exams): Blood pressure: screen for hypertension. Fasting glucose or HbA1c: evaluate for T2DM or insulin resistance. Lipid panel: detect dyslipidemia. Liver function tests: screen for NAFLD. TSH: rule out hypothyroidism. Sleep evaluation: for suspected OSA. Diagnostic Clues: Acanthosis nigricans → insulin resistance. Elevated ALT/AST → fatty liver progression. Gold Standard: Diagnosis is clinical based on BMI, supported by metabolic workup for comorbidities. 5. Management (Exam Concepts) (Conceptual overview only—no dosing or treatment regimens.) 1. Lifestyle Intervention (First-Line) Calorie reduction tailored to nutritional needs. Increased physical activity (aerobic + resistance). Behavioral modification: goal setting, sleep optimization, stress management. 2. Pharmacologic Therapy (Conceptual) Indicated for BMI ≥30 or ≥27 with comorbidities. Mechanisms include appetite suppression, increased satiety, or reduced absorption (no dosing specifics). 3. Bariatric/Metabolic Surgery For BMI ≥40 or ≥35 with comorbidities (T2DM, severe OSA, NAFLD). Produces the largest and most durable weight reduction. Exam clue: resolves or improves T2DM rapidly post-op. 4. Comorbidity Management Treat hypertension, diabetes, dyslipidemia, NAFLD. Screen and treat sleep apnea. Monitor cardiovascular risk factors. Question A 43-year-old woman presents for evaluation of weight gain. She has a BMI of 37 kg/m² and reports daytime fatigue and loud snoring. Physical exam shows a large neck circumference and acanthosis nigricans. Labs reveal elevated fasting insulin and mildly elevated ALT. Which of the following complications is most strongly suggested by these findings? A. HyperthyroidismB. Obstructive sleep apneaC. Addison diseaseD. Primary hyperaldosteronism