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Endo Flashcards

1
Q

Which of the following statements regarding presentation of hypopituitarism is FALSE?

a. GH deficiency causes growth disorders in children and abnormal body composition in adults
b. Gonadotropin deficiency causes menstrual disorders and infertility in women and decreased sexual function, infertility and loss of secondary sexual characteristics in men
c. TSH deficiency causes growth retardation in children and features of hypothyroidism in children and adults
d. Primary ACTH deficiency leads to hypocortisolism and decreased mineralocorticoid production

A

Primary ACTH deficiency leads to hypocortisolism and decreased mineralocorticoid production

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2
Q

Which of the following is the correct sequential order of hormone loss in acquired pituitary hormone deficiency?

a. GH → FSH/LH → TSH → ACTH
b. GH → TSH → ACTH → FSH/LH
c. GH → TSH → FSH/LH → ACTH
d. GH → FSH/LH → ACTH → TSH

A

GH → FSH/LH → TSH → ACTH

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3
Q

Which of the following is a contraindication to growth hormone (GH) replacement therapy in patients with adult GH deficiency?

a. Retinopathy
b. Simple goiter
c. Uncontrolled hypertension
d. Insulin-controlled diabetes

A

Retinopathy

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4
Q

A 30/F with no known comorbidities consulted for primary infertility for one year. Her last menstrual period was 6 months ago. She has had galactorrhea and occasional headache for the past two months. No other symptoms were noted. Physical and neurologic examination was unremarkable. Pertinent work-up revealed negative pregnancy test and elevated serum prolactin level at 250 µg/L. MRI revealed an 8-mm sellar mass. As she is desirous of pregnancy, which of the following is the best treatment for this patient?

a. BromocriptineObservation
b. Bromocriptine
c. Levothyroxine
d. Surgical resection

A

Bromocriptine

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5
Q

In a patient with ACTH-dependent Cushing’s syndrome, which of the following tests is most helpful in differentiating Cushing’s disease from an ectopic ACTH source?

a. Basal ACTH level
b. 24-hour urinary free cortisol
c. Low-dose dexamethasone suppression test
d. High-dose dexamethasone suppression test

A

High-dose dexamethasone suppression test

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6
Q

A patient was found to have a pituitary macroadenoma on MRI after being worked up for blurring of vision, visual field cuts and headache. Extensive work up did not reveal any hormonal excess or deficiency. Which of the following is the treatment of choice for your patient?

a. Observe for now and do serial MRI and visual field testing
b. Bromocriptine
c. Transphenoidal surgery
d. Radiotherapy

A

Transphenoidal surgery

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7
Q

A 45/M is evaluated for increased urination and thirst of several months’ duration. He also notes twice-nightly nocturia. He reveals a diagnosis of bipolar disorder 20 years ago that has been successfully treated with lithium. On PE, BP 110/70 supine and 100/60 standing, HR 88, RR 20. The rest of the PE is normal. Laboratory studies revealed BUN 24 mg/dL, creatinine 132.6 µmol/L, Na 144, K 4.5, Cl 115, HCO3 24, RBS 90 mg/dL, plasma osmolality 320 mOsm/kg and urine osmolality 240 mOsm/kg. Which of the following is the most appropriate diagnostic test to perform to determine the etiology of your patient’s condition?

a. Basal plasma AVP
b. Brain MRI
c. Kidney and urinary bladder ultrasonography
d. Fluid deprivation test

A

Basal plasma AVP

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8
Q

Which of the following thyroid scan findings best describes viral thyroiditis?

a. Low tracer uptake
b. Increased tracer uptake with homogeneous distribution
c. Focal areas of increased uptake with suppressed tracer uptake in the remainder of the gland
d. Multiple areas of relatively increased and decreased tracer uptake

A

Low tracer uptake

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9
Q

Which of the following statements regarding treatment with levothyroxine is true?

a. Patients who miss a dose can be advised to take two doses of the skipped tablets at once since T4 has a long half-life
b. In elderly patients, starting with higher dose is recommended as they usually have higher replacement requirements
c. The dose of levothyroxine should be adjusted based on free T4 levels with the goal of treatment being a normal free T4
d. The clinical effects of levothyroxine can be observed immediately following replacement though normalization of TSH levels may take time

A

Patients who miss a dose can be advised to take two doses of the skipped tablets at once since T4 has a long half-life

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10
Q

A 22/F consulted clinic for a 3-month history of palpitations associated with generalized anxiety and tremors. PE showed BP 110/60, HR 105 regular, anicteric sclerae, grade 1 thyromegaly and fine finger tremors. Tests showed FT4 40 pmol/L (normal value 9-19), TSH 0.1 mIU/mL (NV 0.35-4.9), Hb 120, WBC 10, platelet 300, eGFR 100 mL/min/1.73 m2), ALT 300 U/L (upper limit 42) and normal bilirubins. Which of the following is the best medication to give to address her hyperthyroidism?

a. Methimazole
b. Propylthiouracil
c. Prednisone
d. Lugol’s iodine

A

Methimazole

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11
Q

A 25/F with known Graves’ disease was admitted at the ER for a 1-week history of sore throat and fever. She has regularly taken Methimazole 20 mg/day and Propranolol for the past 4 months. PE findings showed BP 100/60, HR 120 regular, RR 26, temperature 39°C, restlessness, diffuse thyromegaly and hyperemic tonsils with exudates. Pertinent initial tests showed Hgb 105, WBC 2.0, neutrophils 28%, lymphocytes 66%, eosinophils 2%, monocytes 2%, bands 2%; FT4 20 pmol/L (NV 9-19), TSH 0.3 mIU/mL (NV 0.35-4.9). Which of the following is the next best step in the management of this patient?

a. Discontinue Methimazole and do CBC monitoring
b. Lower the dose of Methimazole to 10 mg/day
c. Shift Methimazole to Propylthiouracil
d. Do immediate radioactive iodine therapy

A

Discontinue Methimazole and do CBC monitoring

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12
Q

A 40/F active smoker consulted for palpitations, weight loss and frequent bowel movement. She was tachycardic, with diffuse thyromegaly, lid retraction and fine finger tremors. Which of the following test results are most consistent with her condition?

a. Low TSH, normal FT4, normal FT3
b. Normal TSH, high FT4
c. Low TSH, normal FT4, high FT3
d. High TSH, high FT3

A

Low TSH, normal FT4, high FT3

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13
Q

n the management of well-differentiated thyroid cancer, which of the following is a sensitive marker of residual or recurrent thyroid cancer after thyroidectomy and ablation of the residual postsurgical thyroid tissue?

a. Serum thyroglobulin
b. Whole body thyroid scan
c. Neck ultrasound
d. Neck CT scan

A

Serum thyroglobulin

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14
Q

Which of the following is a marker of residual or recurrent disease in medullary thyroid carcinoma? (HPIM, C378, P2717)

a. Serum calcitonin
b. Serum thyroglobulin
c. Free T4
d. Serum LDH

A

Serum calcitonin

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15
Q

A 30/M is being evaluated for resistant hypertension despite intake of Carvedilol, Amlodipine, Losartan, and Hydrochlorothiazide. The initial work-up showed a normal urinalysis, eGFR 90 mL/min/1.73 m2, K 3.0, Na 135 and an unremarkable ultrasound of the kidneys. Screening and diagnostic tests confirmed mineralocorticoid excess. Which of the following is the most likely diagnosis? (HPIM, C379, P2729)

a. Cushing syndrome
b. Liddle’s syndrome
c. Primary aldosteronism
d. Pheochromocytoma

A

Primary aldosteronism

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16
Q

A patient was referred for an incidentally discovered adrenal mass measuring 6 cm with CT density of 25 Hounsfield units (HU). Tests for hormonal excess were all normal. What is the recommended management for this patient?

a. Unilateral adrenalectomy
b. Repeat screening for hormone excess after 12 months
c. Do CT-guided FNAB of the adrenal mass
d. No further evaluation needed

A

Unilateral adrenalectomy

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17
Q

A 19/F is evaluated for primary amenorrhea. Her cognitive function is normal and she is not sexually active. Her personal history and family medical history are unremarkable, with no intake of any supplements or medications. PE revealed normal vital signs and BMI; height 147 cm; normal secondary sexual characteristics; and Tanner stage 4 breast and pubic hair development. Which of the following is the recommended step in the evaluation of her condition? (HPIM, C386, P2796)

a. Rule out any uterus and outflow tract anomaly by imaging
b. Send for a B-HCG assay
c. Send for serum FSH
d. Rule out eating disorders

A

Rule out any uterus and outflow tract anomaly by imaging

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18
Q

Which of the following is a contraindication to postmenopausal hormone therapy? (HPIM, C387, P2810)

a. History of transient ischemic attack
b. One or more first-degree relatives with ovarian cancer
c. Elevated LDL
d. Prior cholecystectomy

A

History of transient ischemic attack

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19
Q

A 23 year old pregnant patient was referred to you for evaluation of gestational diabetes. When is screening recommended if she has no risk factors? (UNITE CPG P32)

a. 16-20 weeks AOG
b. 16-24 weeks AOG
c. 24-28 weeks AOG
d. On her first prenatal check-up

A

24-28 weeks AOG

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20
Q

Which of the following is contraindicated among patients with medullary thyroid carcinoma? (HPIM, C397, P2866)

a. DPP-4 inhibitors
b. GLP-1 receptor agonists
c. Thiazolidinediones
d. Biguanides

A

GLP-1 receptor agonists

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21
Q

A 59/F was referred for fasting blood sugar of 250 mg/dL. For the past three months, she noted polyuria, polydipsia and fatigue. She was previously diagnosed with heart failure from ischemic heart disease. Physical exam was unremarkable save for BMI 28 kg/m2 and BP 140/90. Initial tests showed HbA1c 8.5%, eGFR 92 mL/min/1.73 m2 and normal liver enzyme tests. Knowing that this patient may benefit from combination therapy, which among the following agents is the best add-on to metformin? (HPIM, C396, P2866 T397-5)

a. Acarbose
b. Glibenclamide
c. Canagliflozin
d. Pioglitazone

A

Canagliflozin

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22
Q

Which lipid lowering drug has been shown to reduce the progression of retinopathy without reducing cardiovascular events? (HPIM, C398, P2877)

a. Atorvastatin
b. Fenofibrate
c. Niacin
d. Cholestyramine

A

Fenofibrate

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23
Q

A 38/F consulted about having diabetes despite being asymptomatic. Her parents and two siblings have type 2 diabetes mellitus. Last year, her father began chronic hemodialysis. PE showed BMI 28 kg/m2 and waist circumference 88 cm, while the rest of the findings were unremarkable. Based on the UNITE CPG for the Diagnosis and Management of Diabetes, when is it appropriate to screen for diabetes and repeat the test if results are normal? (CPG UNITE)

a. Now then every year thereafter
b. Now then every three years
c. Age 40 then every year thereafter
d. Age 40 then every three years

A

Now then every year thereafter

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24
Q

What is the expected level of C-peptide in a patient with hypoglycemia caused by intake of exogenous insulin? (HPIM20 C399 P2888)

a. Normal
b. Low
c. High
d. Undetectable

A

Low

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25
Q

A 33/M presents with neck pain and persistent palpitations. He also reports having cough, cold and throat pain 2 weeks ago. His physical examination reveals a tender neck mass. What is expected of the depressed TSH level in this patient? (HPIM20 C377 P2708 F377-3)

a. It will normalize on the 12th week of illness
b. It will increase by the 6th week of illness
c. It will increase by the 18th week of illness
d. It will further decrease by the 4th week of illness

A

It will increase by the 6th week of illness

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26
Q

Which of the following genetic syndromes associated with pituitary tumors also present with pigmented skin patches and polyostotic fibrous dysplasia? (HPIM, C2373, P2674)

a. Carney complex
b. MEN4
c. McCune-Albright syndrome
d. Familial pituitary adenoma

A

McCune-Albright syndrome

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27
Q

What is the initial treatment of choice for patients with growth hormone (GH)-secreting adenomas? (HPIM, C2373, P2679)

a. Surgery
b. Dopamine agonists
c. Somatostatin analogue
d. Radiation therapy

A

Surgery

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28
Q

Which of the following is the clinical hallmark of primary aldosteronism? (HPIM, C379, P2729)

a. Hyponatremic hypertension
b. Hypokalemic hypertension
c. Hyponatremic hypotension
d. Hypokalemic hypotension

A

Hypokalemic hypertension

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29
Q

A 35/M was referred for resistant hypertension despite intake of diuretics and three other antihypertensive drug classes. Workup revealed persistent hypokalemia and presence of an adrenal mass. Which of the following is the appropriate screening test given the clinical suspicion of hormone excess? (HPIM, C379, P2729)

a. Saline infusion test
b. Fludrocortisone suppression test
c. Aldosterone-renin ratio
d. Oral sodium loading test

A

Aldosterone-renin ratio

30
Q

Which of the following medications is a synthetic analogue of AVP that selectively acts at V2 receptors to increase urine concentration and decrease urine flow among patients with uncomplicated diabetes insipidus? (HPIM, C374, P2687)

a. Desmopressin
b. Tolvaptan
c. Pasireotide
d. Conivaptan

A

Desmopressin

31
Q

Which of the following thyroid medications is associated with the development of choanal atresia and tracheoesophageal fistulae? (HPIM, C377, P2707)

a. Methimazole
b. Propranolol
c. Propylthiouracil
d. Stable iodide

A

Methimazole

32
Q

Which of the following sonographic features is the least associated with thyroid cancer? (HPIM, C378, P2711)

a. Marked hyperechogenicity
b. Presence of microcalcifications
c. Presence of irregular, microlobulated margins
d. Solid consistency

A

Marked hyperechogenicity

33
Q

Which of the following patients fulfill a diagnosis of pre-diabetes? (HPIM, C396, P2850)

a. HbA1c 6.5%
b. 2-h plasma glucose after 75 g OGTT 7.8 mmol/L
c. Fasting plasma glucose 7.0 mmol/L
d. Random plasma glucose 120 mg/dL

A

2-h plasma glucose after 75 g OGTT 7.8 mmol/L

34
Q

Which of the following is recommended for patients with type 1 DM to avoid exercise-related hyper- or hypoglycemia? (HPIM, C396, P2861)

a. Monitor blood glucose during strenuous exercise
b. Delay exercise if blood sugar is more than 200 mg/dL and ketones are present
c. Ingest carbohydrate before exercising if blood glucose is less than 120 mg/dL
d. Decrease insulin doses (based on previous experience) before and after exercise and inject insulin into a nonexercising muscle

A

Decrease insulin doses (based on previous experience) before and after exercise and inject insulin into a nonexercising muscle

35
Q

Which of the following patients has a clear indication for BMD testing? (HPIM, C404, P2947)

a. 65/F with no known comorbidities
b. 65/M with no known comorbidities
c. 45/F with recent fracture of the hip
d. 45/F with newly diagnosed SLE on prednisone 10 mg/day for 1 month

A

65/F with no known comorbidities

36
Q

Based on the recommendation of the Institute of Medicine, what is the recommended adequate daily calcium intake for men and women aged 51 and above? (HPIM, C404, P2951)

a. 800 mg/day
b. 1000 mg/day
c. 1200 mg/day
d. 1300 mg/day

A

1200 mg/day

37
Q

A 48-year-old male sought consult for his annual company check-up. He is asymptomatic. His mother is Diabetic and his father is Hypertensive. His body mass index is 25.3kg/m2. Patient had blood examination as part of his routine company check-up. Given his above clinical features, which of his laboratory findings can be considered as an additional risk factor that predisposes him to develop Type 2 DM?

a. Triglycerides= 2.77 mmol/L
b. 2H PG= 7.6 mmol/L
c. HbA1c= 5.6%
d. HDL= 0.80 mmol/L

A

d. HDL= 0.80 mmol/L

38
Q

. A 22-year-old Type 1 Diabetic patient plans to engage in physical activity and attend regular gym sessions. What should you prescribe him?

a. Ingest carbohydrate before exercising if blood glucose is 6mmol/L.
b. Delay exercise if blood glucose is 12mmol/L and ketones are present.
c. Monitor glucose during exercise and ingest carbohydrate to prevent hypoglycemia.
d. Increase insulin doses (based on previous experience) before and after exercise and inject insulin into a non-exercising area.

A

c. Monitor glucose during exercise and ingest carbohydrate to prevent hypoglycemia.

39
Q

Which of the following anti-diabetic drugs may cause angioedema as well as urticarial and immune-mediated dermatologic effects?

a. Linagliptin
b. Glimepiride
c. Repaglinide
d. Empagliflozin

A

a. Linagliptin

40
Q

A 19-year-old female, known Diabetic with poor compliance to medication was rushed to the ER due to abdominal pain and vomiting. Upon assessment, the following findings were noted:
Vital Signs:
BP= 130/70, HR=105, RR=26
Temperature=37.6C
Drowsy, in respiratory distress.
Initial laboratory work-up showed:
CBG= high
ABG= uncompensated metabolic acidosis
Serum Ketone= positive.

Her condition can be explained by which mechanism?

a. Glucagon excess that increases the activity of pyruvate kinase.
b. Insulin deficiency which decreases the activity of phosphoenolpyruvate carboxykinase.
c. The combination of insulin deficiency and hyperglycemia reduces the hepatic level of fructose-2,6-bisphosphate.
d. Insulin deficiency enhances the levels of the GLUT4 glucose transporter, which impairs glucose uptake into skeletal muscle.

A

c. The combination of insulin deficiency and hyperglycemia reduces the hepatic level of fructose-2,6-bisphosphate.

41
Q

A 21-year-old male came to the ER due to nausea, vomiting, abdominal pain and generalized weakness.
Vital signs were as follows:

BP=110/70, HR=108 RR=28,
Temperature= 38.9.
Initial laboratory work-up showed:
CBG= high
ABG= uncompensated metabolic acidosis
Plasma Ketone= positive
Appropriate management of this case includes:

a. Replacement of potassium at 10meqs/hr if the potassium is <3.5mmol/L in the next 24 hours. b. If the serum phosphate is <0.32mmol/L, then phosphate supplementation should be
considered.
c. In case of severe acidosis (pH< 7.0), compute for the bicarbonate deficit and replace it in 12 to 24 hours until pH is 7.0.
d. When the plasma glucose reaches 300mg/dL, glucose should be added to the 0.45% saline infusion to maintain the plasma glucose in 250 mg/dL range, and the insulin infusion should be continued at a lower rate.

A

b. If the serum phosphate is <0.32mmol/L, then phosphate supplementation should be
considered.

42
Q

A 55-year-old female, known Diabetic and Hypertensive for 8 years has been complaining of persistent distal symmetrical lower extremity pain despite having a good glycemic, blood pressure and lipid control. He has no known vices. Your recommendation is to initiate an FDA-approved drug for her condition which includes:

a. Tramadol
b. Duloxetine
c. Gabapentin
d. Amitriptyline

A

b. Duloxetine

43
Q

A 48-year-old male, known Diabetic sought consult with the following lipid profile:
Triglycerides= 568mg/dL
HDL=28mg/dL
LDL= 64mg/dL
The patient is already on lifestyle modification for the past 6 months. Which medication can be prescribed to him to reduce his risk of pancreatitis?
a. Bile acid sequestrants
b. Nicotinic acid
c. Fenofibrate
d. Statin

A

c. Fenofibrate

44
Q

A 34-year-old female consulted due to weight gain. Her waist circumference is 35 inches and her body mass index is 30kg/m2. She has no other co-morbidities. Which of the following pulmonary abnormalities may be associated with her condition?
a. decreased minute ventilation
b. increased chest wall compliance
c. decreased expiratory reserve volume
d. increased functional residual capacity

A

c. decreased expiratory reserve volume

45
Q

A 22-year-old female presented with hypogonadotropic hypogonadism, hyperphagia-obesity, chronic muscle hypotonia, mental retardation, and diabetes mellitus. She also has multiple somatic defects that involves her skull, eyes, ears, hands, and feet. What is the most likely diagnosis?

a. Turner syndrome
b. Kallmann Syndrome
c. Bardet-Biedl Syndrome
d. Prader-Willi Syndrome

A

d. Prader-Willi Syndrome

46
Q

A 32-year-old female sought consult due amenorrhea, galactorrhea and infertility. Her initial serum Prolactin was 950 ng/mL (normal: 1.9-25ng/mL). The rest of pituitary hormone levels were normal. Pituitary MRI revealed a 2.3 x 1.9 x 1.5 cm mass in the anterior pituitary gland. Patient would want to conceive. She is taking titrated doses of Bromocriptine for 12 months. Her latest Prolactin is 835 ng/mL. She also developed blurring of vision and intermittent episodes of headache. Repeat MRI does not show tumor shrinkage. What will be the next step in management?
a. Start Estrogen.
b. Add Octreotide to Bromocriptine
c. Continue titrating the dose of Bromocriptine until maximum dose is achieved.
d. Refer to Neurosurgery for transphenoidal resection of tumor

A

d. Refer to Neurosurgery for transphenoidal resection of tumor

47
Q

A 29-year-old male sought consult for coarse facial features and progressively enlarging hands and feet. He also complained of hyperhidrosis and arthralgia. He has bitemporal hemianopsia on visual field exam. His vital signs are stable.
His initial laboratory work-up showed:
Growth hormone: 56.9 ng/mL (normal: 0-5 ng/mL), taken when patient was fasting
IGF-1: elevated
Rest of pituitary hormone: normal
Fasting blood sugar: 117 mg/dL
Colonoscopy: no polyp or mass
ECG: regular sinus rhythm, normal axis with left ventricular hypertrophy
What should you do next?

a. Repeat IGF-1 on fasting and stimulated state
b. Request for pituitary, chest and abdominal CT-scan
c. Determine growth hormone level after 75 grams oral glucose load
d. No further work-up needed. Proceed with definitive treatment.

A

c. Determine growth hormone level after 75 grams oral glucose load

48
Q

A 30-year-old male was diagnosed with Acromegaly. He had persistent headache and blurring of vision. Initial evaluation showed that the likelihood of surgical cure is low. He still underwent debulking surgery. On his regular follow-up for the past 6 months, his IGF is still elevated. What should be the next step in management?
a. Start Somatostatin analogue
b. Refer to Radiology for Radiotherapy
c. Refer to Neurosurgery and schedule for repeat debulking surgery
d. Reassure the patient that he needs to wait after 12 months to see improvement in his
condition.

A

a. Start Somatostatin analogue

49
Q

A 32-year-old female consulted due to facial plethora, proximal muscle weakness, easy bruisability, menstrual irregularity, and obesity. She had no known exposure to any medication that contains steroids. Her initial laboratory features showed elevated 24-hour urinary cortisol, elevated salivary cortisol and elevated serum ACTH. High dose dexamethasone suppression test was also done which revealed suppressed level of cortisol, less than 5ug/dL. What should you do next?

a. Start Mitotane
b. Perform pituitary MRI
c. Request for chest, abdominal and pelvic CT-Scan
d. Refer to Neurosurgery and schedule for pituitary surgery as soon as possible

A

b. Perform pituitary MRI

50
Q

A 34-year-old male patient came in due to complaints of increase urinary frequency and volume, amounting to 90 mL/kg. He weighs 88 kilograms.
His laboratory results are as follows:
24 hour Urine volume: almost 8500 cc
Urine osmolarity: 230 mosm/Liter
Urine specific gravity: 1.001
Basal plasma arginine vasopressin: 5pg/mL
Pituitary MRI result showed presence of bright spot.
Based on the above findings, which is the most likely diagnosis?

a. Pituitary Diabetes Insipidus
b. Nephrogenic Diabetes Insipidus
c. Primary Poyldipsia- Dipsogenic Type
d. Primary Polydipsia- Psychogenic Type

A

b. Nephrogenic Diabetes Insipidus

51
Q

A 65-year-old female being managed as a case of lung malignancy was referred due to persistent hyponatremia. The patient does not have CHF, CKD, CLD, thyroid or adrenal disease. The patient does not experience increase diuresis or bowel movement. Clinically, the patient is euvolemic. Which of the following findings will be consistent with the possible cause of her hyponatremia?

a. low urate
b. low urinary sodium
c. elevated potassium
d. elevated plasma renin activity

A

a. low urate

52
Q

Who among these patients are at increased risk for generalized osteoporosis?

a. L.Q., 38-year-old male with elevated TSH and low fT4
b. M.C., a 40-year-old female with low level of Prolactin
c. A.F, a 42-year-old male with low cortisol and ACTH
d. S.D., a 44-year-old female with HbA1c of 5.6% and FBS of 5.5mmol/L

A

c. A.F, a 42-year-old male with low cortisol and ACTH

53
Q

Who among these patients will need a vertebral imaging test to screen for osteoporosis?

a. E.Z., a 48-year-old female who had low-trauma fracture at age 45
b. P.D., 52-year-old male with historical height loss of 1.6 inches
c. I.G., 59-year-old-female with prospective height loss of 0.6 inches.
d. R.V., 67-year-old male with BMD T-score at the spine, total hip, or femoral neck of 2.0

A

b. P.D., 52-year-old male with historical height loss of 1.6 inches

54
Q

A 66-year-old female being treated for osteoporosis developed dermatitis, rash and eczema. After undergoing dental procedure, she had Osteonecrosis of the Jaw. Her serum calcium was checked and it was low. What is the most likely medication that the patient is taking and eventually predisposes her to this condition?

a. Calcitonin
b. Tamoxifen
c. Denosumab
d. Abaloparatide

A

c. Denosumab

55
Q

A 59-year-old female consulted due to easy fatigability, weakness, constipation and weight gain. She also has puffy face with edematous eyelids and nonpitting pretibial edema. Initial laboratory revealed elevated TSH and low fT4. What should you order to establish her diagnosis?
a. fT3
b. TPO Ab
c. TSH-Receptor Ab
d. Thyroid Ultrasound

A

b. TPO Ab

56
Q

A 35-year-old female was referred by her Ob-Gynecologist due to easy fatigability, menstrual irregularity and constipation. Part of her work-up revealed a normal TSH and low fT4 and fT3. Thyroid function tests were done twice and yielded same results. She has no known co-morbidities. She is not taking any medications. What should be the next step in managing this patient?
a. Evaluate pituitary function.
b. Facilitate a thyroid scan with uptake
c. Observe and repeat thyroid function tests after 3 months.
d. No further work-up needed. Start treatment with Levothyroxine.

A

a. Evaluate pituitary function.

57
Q

A 38-year-old male, previously diagnosed with Graves’ Disease, underwent Radioactive Iodine Therapy consulted with an elevated TSH and low fT4. He weighs 73kg. What is his computed dose of Levothyroxine?
a. 104.9 ug
b. 116.8 ug
c. 128.6 ug
d. 129.3 ug

A

b. 116.8 ug

58
Q

A 35-year-old female was referred to you for co-management of her infertility. She is clinically euthyroid. She has no known heart disease. For the past 3 months, her Ob-Gynecologist told you that her TSH is above 10 mIU/L. Her current TSH is 15 mIU/L. Her ft4 and ft3 are both normal. What is the best management option for her condition?

a. Facilitate pituitary MRI as soon as possible.
b. Observe and repeat thyroid function test after 4 to 6 weeks.
c. You can tell her to start treatment with Levothyroxine.
d. Reassure the patient that there is no need to start treatment or do further work-up.

A

c. You can tell her to start treatment with Levothyroxine.

59
Q

A 65-year-old female was rushed to the ER due to decreasing sensorium. She was previously diagnosed with unrecalled thyroid disease, non-compliant to medication and was lost to follow-up. She is bradycardic and hypothermic. She also has generalized edema. Work-up revealed elevated TSH and low fT4. Her Chest X-Ray revealed pneumonia on right lower lung field. What should be part of her management?

a. Hypotonic IV fluids should be preferred if available.
b. Parenteral hydrocortisone (50mg every 6 h) should be administered.
c. An initial loading dose of 30-50 μg Liothyronine should be followed by 2.5–10 μg 8 hourly, with lower doses for those at cardiovascular risk.
d. Levothyroxine can initially be administered as a single IV bolus of 200–400 μg, which serves as a loading dose, followed by a daily oral dose of 1.6 μg/kg/d, increased by 25% if administered IV.

A

b. Parenteral hydrocortisone (50mg every 6 h) should be administered.

60
Q

A 29-year-old male consulted due to palpitations, tremors, hyperdefecation and weight loss. Upon assessment, the following findings were noted:
Vital Signs: BP= 140/90, HR=108, RR=20 Temperature=36.8C
He is hyperreflexic.
There are no other significant physical examination findings.
Initial laboratory tests showed suppressed TSH and normal fT4.

What should be the next step in managing this case?
a. Do fT3
b. Do TPO Ab
c. Facilitate thyroid ultrasound.
d. Request for dedicated pituitary MRI.

A

a. Do fT3

61
Q

A 32-year-old male consulted due to symptoms of thyrotoxicosis. There was no thyroid-related eye disease as well as thyromegaly. Thyroid function tests which were done twice showed normal TSH and elevated fT4 and fT3. What is his most likely diagnosis?

a. de Quervain’s thyroiditis
b. Sick Euthyroid Syndrome
c. Subclinical Hyperthyroidism
d. TSH-secreting Pituitary Adenoma

A

d. TSH-secreting Pituitary Adenoma

62
Q

A 29-year-old female consulted due to symptoms of thyrotoxicosis. There was no thyroid-related eye disease as well as thyromegaly. There was also no palpable nodule or mass. Thyroid function tests which were done twice showed suppressed TSH and elevated fT4. Thyroid scan was also done which revealed low radioactive iodine uptake. What is her most likely diagnosis?

a. Iodine Excess
b. Toxic Adenoma
c. TSH-secreting Pituitary Adenoma
d. Rule out other causes including stimulation by chorionic gonadotropin

A

a. Iodine Excess

63
Q

A 34-year-old female consulted due to 4-week symptoms of palpitations, fever, hyperdefecation associated with painful thyroid gland radiating to the jaw. Eye examination did not show exophthalmos, retraction or lid lag. Neck examination did not reveal thyromegaly or mass or nodule. Thyroid function test results showed suppressed TSH and elevated fT4. Thyroid scan showed low radioactive iodine uptake. Which of the following is part of the appropriate management plan for this patient?

a. Aspirin 80mg/tablet may be given at a dose of 5-6 tablets every 4-6 hours.
b. Either PTU or Methimazole can be given during the thyrotoxic phase, but preferably Methimazole.
c. Levothyroxine replacement may be needed if the hypothyroid phase is prolonged, but doses should be 50–100 μg/day
d. If Aspirin or NSAID is not sufficient, Prednisone may be given at a dose of 3-4mg/kg/day for 8 to 12 weeks and must be tapered based on patient’s symptoms.

A

c. Levothyroxine replacement may be needed if the hypothyroid phase is prolonged, but doses should be 50–100 μg/day

64
Q

A 27-year-old female was referred for evaluation of possible thyroid disease. She is clinically euthyroid. She has no known co-morbidities. Upon assessment, the following findings were noted:
Vital Signs: BP= 120/70, HR=90, RR=16 Temperature=36.5C
There are no other significant physical examination findings.
Initial laboratory tests showed suppressed TSH and normal unbound thyroid hormones.
What should be the next step in managing this case?

a. Do thyroid ultrasound.
b. Request for dedicated pituitary MRI.
c. Follow up in 6-12 weeks with repeat thyroid function tests.
d. No further work-up needed and start treatment with Methimazole.

A

c. Follow up in 6-12 weeks with repeat thyroid function tests.

65
Q

A 36-year-old female came in due to palpable nodule on her neck. She was clinically euthyroid. There were no complaints of hoarseness, dysphagia or odynophagia. On neck palpation, an approximately 2.5 x 1.5 cm mass was palpated on her left thyroid gland. There was no palpable lymph node. TSH was suppressed. What should be the next best step in managing this patient?

a. Request for radionuclide scan
b. Start treatment with Methimazole
c. Refer to surgery and schedule for lobectomy
d. Do Fine Needle Aspiration Biopsy of the thyroid nodule

A

a. Request for radionuclide scan

66
Q

A 40-year-old-female came for palpable solitary thyroid nodule on the right lobe. Her previous physician requested thyroid function test which revealed normal TSH. Thyroid ultrasound revealed the following results: Right lobe: 5.7 x 3.6x 2.5 cm, with nodule described as hypoechoic, with calcifications, measuring 2.2 x 1.5 x 1.3 cm. Left lobe: 4.1 x 3.9 x 2.4 cm. Isthmus: 1.5 x 1 x 0.5 cm
No cervical lymphadenopathy. She had fine needle aspiration biopsy that showed Suspicious for Papillary Thyroid Cancer. She was advised by her previous physician to undergo immediate surgery. She consulted you for 2nd opinion. What will you advise her?

a. Repeat fine needle aspiration biopsy, this time ultrasound guided.
b. Consider doing thyroid scan first to check if it is a hot or cold nodule
c. Immediately advise patient to undergo total thyroidectomy followed by radioactive iodine therapy and levothyroxine suppression therapy.
d. Do thyroid peroxidase and thyroglobulin antibodies to rule out the possibility of
Hashimoto’s thyroiditis that may increase likelihood of co-existing thyroid lymphoma.

A

c. Immediately advise patient to undergo total thyroidectomy followed by radioactive iodine therapy and levothyroxine suppression therapy.

67
Q

A 29-year-old female consulted due to progressive weight gain, easy bruisability, proximal myopathy, purplish abdominal striae >1cm, diabetes mellitus, dyslipidemia and hypertension. There were no known co-morbidities. Patient denies use of steroids. Initial work-up revealed elevated midnight salivary cortisol and suppressed ACTH. How should you proceed with work-up?

a. Do pituitary gland MRI
b. Do adrenal gland CT-Scan
c. Perform High Dose Dexamethasone Suppression Test
d. Refer to Interventional Radiologist for Inferior Petrosal Sinus Sampling

A

b. Do adrenal gland CT-Scan

68
Q

A 31-year-old male suspicious of Cushing’s syndrome had a non-suppressible low dose dexamethasone suppression test and an elevated 24-hour urine free cortisol levels. Serum ACTH was elevated. Pituitary Magnetic Resonance Imaging showed a pituitary mass, 1.2 cm x 0.9 cm x 0.8 cm. High dose dexamethasone suppression test was done and results showed non-suppressed level of cortisol. CRH test done showed non-stimulated levels of ACTH and cortisol. What should be the next plan of management?
a. Start Mitotane followed by Radiotherapy
b. Transphenoidal excision of pituitary mass
c. Perform inferior petrosal sinus sampling
d. Subject patient to adrenal gland protocol then treat with Ketoconazole

A

c. Perform inferior petrosal sinus sampling

69
Q

A 32-year-old female consulted due to progressive weight gain, easy bruisability, proximal myopathy, purplish abdominal striae >1cm, impaired glucose tolerance and hypertension. There were no known co-morbidities. Patient denies use of steroids. Initial work-up revealed 4 times elevated urinary cortisol and elevated ACTH. Which of the following is the most likely diagnosis?

a. Macronodular Adrenal Hyperplasia
b. McCune-Albright Syndrome
c. Adrenocortical adenoma
d. Ectopic ACTH Syndrome

A

d. Ectopic ACTH Syndrome

70
Q

A 44-year-old male was diagnosed with Primary Aldosteronism based on a positive Aldosterone-Renin Ratio and an elevated aldosterone levels on confirmatory test. On history, he claimed that most of the time, his blood pressure was 140-150/90mmHg and serum potassium was normal. There is no family history of early-onset hypertension or Primary Aldosteronism. Imaging revealed bilateral micronodular hyperplasia. What will be your next plan of action?

a. Schedule for Adrenal Vein Sampling
b. Do Fludrocortisone Suppression Test
c. Start treatment with Spironolactone
d. Refer to Urologist for Bilateral Adrenalectomy

A

c. Start treatment with Spironolactone

71
Q

A 43-year-old female came in due to generalized weakness, nausea, dizziness, vomiting and abdominal pain. Blood pressure was 90/60mmHg. Capillary blood glucose was 68mg/dL. She was suspected to have Adrenal Insufficiency hence she had cosyntropin test that revealed low level of cortisol. Further diagnostic exam showed low ACTH, normal renin and normal aldosterone. There was no history of previous steroid intake. How should you proceed with the diagnostic work-up?

a. Screen for autoantibodies
b. Facilitate Insulin Tolerance Test
c. Do CT-Scan of chest and abdomen
d. Perform MRI of the pituitary gland

A

d. Perform MRI of the pituitary gland

I (12 decks)

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