ENDO Flashcards
A 22/M presented with prognathism and increased hand and foot size. Pertinent workup showed a large pituitary adenoma on cranial CT scan with contrast. Despite undergoing transsphenoidal surgery, his IGF-I levels remain elevated. Which of the following drugs can be added next as adjuvant treatment? (HPIM C373 p2680 fig. 373-5)
a. Octreotide
b. Pegvisomant
c. Bromocriptine
d. Mitotane
The correct answer is: Octreotide
Which of the following characteristics about ACTH-secreting pituitary tumors best differentiate it from ectopic ACTH secretion? (HPIM C373 p2681 table 373-8)
a. 24 hour urine free cortisol is elevated
b. Cortisol is <5 ug/dL after high-dose dexamethasone suppression
c. Associated with pigmentation and rapid onset of clinical features
d. Basal inferior petrosal : peripheral vein ACTH ratio is <2
The correct answer is: Cortisol is <5 ug/dL after high-dose dexamethasone suppression
Which of the following statements is true regarding non-functioning pituitary adenomas? (HPIM C373 p2682)
a. They are the most common type of pituitary adenoma.
b. They are usually microadenomas at the time of diagnosis.
c. Most clinically non-functioning adenomas originate from lactotrope cells.
d. They are responsive to treatment with dopamine agonists.
The correct answer is: They are the most common type of pituitary adenoma.
A 60/F with squamous cell lung CA stage IV is referred for an incidental finding of low serum sodium (125 mEq/L). Patient denies having nausea or vomiting. Her BP was 120/80 with clear breath sounds and no edema on PE. Which of the following strategies is best suited to correct her hyponatremia? (HPIM C374 p2690-2691)
a. Give 0.05 mL/kg/min hypertonic saline to target sodium of 130 mEq/L
b. Give 1 mL/kg/hr plain saline to target sodium of 130 mEq/L
c. Give sodium chloride 1g/tab 3x a day
d. Give tolvaptan 15 mg/tab 1x a day
The correct answer is: Give tolvaptan 15 mg/tab 1x a day
Which of the following statements is true regarding diagnostic workup for adrenal incidentalomas? (HPIM C379 p2731)
a. MRI with GAD is the procedure of choice for imaging the adrenal glands.
b. FNA or CT-guided biopsy of an adrenal mass is rarely indicated.
c. Tumor density can reliably differentiate adrenal adenomas from carcinomas
d. Tumors >4 cm are more likely malignant with a 90% specificity
The correct answer is: FNA or CT-guided biopsy of an adrenal mass is rarely indicated.
Which of the following features present in primary adrenal insufficiency best distinguish it from secondary adrenal insufficiency? (HPIM C379 p2734-2735)
a. Alabaster-colored skin
b. Hyponatremia
c. Hyperreninemia
d. Low blood pressure
The correct answer is: Hyperreninemia
Which of the following enzymes is deficient in the most common form of congenital adrenal hyperplasia? (HPIM C383 p2767)
a. 21-hydroxylase
b. 17α -hydroxylase
c. 11-hydroxylase
d. 3β-hydroxysteroid dehydrogenase
The correct answer is: 21-hydroxylase
A 28/F with previously normal menses consults for amenorrhea of 4 months duration. An extensive workup revealed no uterine tract abnormalities and negative pregnancy test. Hormone levels revealed normal prolactin and testosterone levels with increased LH and FSH levels. Which of the following is the most likely cause of her amenorrhea? (HPIM C386 p2796 fig 386-2)
a. Hypothalamic amenorrhea
b. Idiopathic hypogonadotropic hypogonadism
c. Primary ovarian insufficiency
d. Polycystic ovarian syndrome
The correct answer is: Primary ovarian insufficiency
According to the Women’s Health Initiative Estrogen-Progestin and Estrogen-Alone Trials, estrogen-progestin postmenopausal hormone therapy causes a definite increase in risk in the incidence of which of the following diseases? (HPIM C388 p2805 table 388-1)
a. Coronary heart disease
b. Ovarian cancer
c. Pulmonary embolism
d. Endometrial cancer
The correct answer is: Pulmonary embolism
A 40/M with T2DM and hypertriglyceridemia has a BMI of 35. What would be the best approach for the treatment of his obesity? (HPIM C395 p 2846 table 395-4)
a. Advise to decrease daily calorie intake by 750 kcal/day
b. Encourage to engage in 75 minutes/week of vigorous-intensity aerobic physical activity
c. Start phentermine/topiramate and orlistat
d. Refer for bariatric surgery
The correct answer is: Refer for bariatric surgery
Which of the following statements are true regarding the criteria for the diagnosis of diabetes mellitus? (HPIM C397 p 2852 table 396-2)
a. The OGTT is the most reliable test for identifying DM in asymptomatic individuals.
b. An individual with a HbA1c of 6.5 during his first set of tests can be diagnosed with DM.
c. The current criteria allow for the diagnosis of DM to be withdrawn when glucose tolerance becomes normal.
d. Race and ethnicity have little impact in the reliability of HbA1c since it is standardized.
The correct answer is: The current criteria allow for the diagnosis of DM to be withdrawn when glucose tolerance becomes normal.
At what age does ADA recommend initiating screening for all individuals? (HPIM C397 p2853)
a. 35
b. 40
c. 45
d. 50
The correct answer is: 45
Which of the following best describes the genetic mechanisms behind diabetes mellitus? (HPIM C396 p2855-2856)
a. Most individuals with Type 1 DM do not have a first-degree relative with this disorder.
b. The concordance of Type 2 DM in identical twins is between 40 and 60%.
c. Type 1 DM is polygenic and multifactorial because environmental factors (e.g. obesity) also modulate the phenotype.
d. The risk of developing Type 2 DM in relatives of individuals with the disease is relatively low.
The correct answer is: Most individuals with Type 1 DM do not have a first-degree relative with this disorder.
According to ADA, which of the following drugs can be considered to prevent or delay onset of T2DM in individuals with both IFG and IGT and are at a very high risk for progression to diabetes? (HPIM C396 p2857)
a. Acarbose
b. Metformin
c. Orlistat
d. Pioglitazone
The correct answer is: Metformin
Which of the following clinical characteristics will be most consistent with a patient with new-onset Type 2 DM? (HPIM C396 p2858)
a. Elevated blood pressure
b. Propensity to develop ketoacidosis
c. Increased risk to develop autoimmune disorders
d. Lean body habitus
The correct answer is: Elevated blood pressure
A 36/M with Type 1 DM on insulin glargine and glulisine is an active jogger who experiences frequent episodes of light headedness during his regular routine. What would be the best advise to give him to prevent these episodes? (HPIM C397 p2861)
a. Delay jogging if blood glucose is >300 mg/dL and ketones are present.
b. Eat bread before jogging if blood glucose is <150 mg/dL.
c. Decrease insulin dose before and maintain insulin dose after jogging.
d. Inject insulin into a non-exercising area.
The correct answer is: Inject insulin into a non-exercising area.
Which of the following statements is true regarding the properties of glycated hemoglobin? (HPIM C397 p 2862).
a. It detects glycemic variability like self-monitoring of blood glucose
b. Glycemic level in the preceding month contributes about 70% to the HbA1c value.
c. Recent intercurrent illnesses can impact HbA1c.
d. Nocturnal hyperglycemia will be reflected in the HbA1c.
The correct answer is: Nocturnal hyperglycemia will be reflected in the HbA1c.
Which of the following statements most accurately reflect frequently used insulin regimens in Type 1 DM? (HPIM C397 p 2864).
a. In general, Type 1 DM patients require 1-2 units/kg per day of insulin.
b. A common insulin-to-carbohydrate ratio is 1 unit per 15 g of carbohydrate.
c. Insulin is given as multiple doses with 70% given as basal insulin.
d. Supplemental insulin is given at 2 units of insulin for every 50 mg/dL over glucose target.
The correct answer is: A common insulin-to-carbohydrate ratio is 1 unit per 15 g of carbohydrate.
A 70/F with T2DM on metformin complains of frequent nausea, diarrhea and anorexia. Since she is not able to eat properly, she has intermittent episodes of light headedness and blurring of vision. Her current HBA1c is 8.5. Which of the following glucose-lowering agents is best suited for her in place of metformin? (HPIM C397 p 2866 table 397-5)
a. Dapagliflozin
b. Miglitol
c. Repaglinide
d. Glimepiride
The correct answer is: Dapagliflozin
A 45/F with Type 2 DM has been taking Metformin 500 mg BID for the past 3 years. Her latest HbA1c is 9.0 and her BMI has been steadily increasing, now at 32. What add-on glucose-lowering agent will benefit her the most? (HPIM C397 p 2866 table 397-5)
a. Pioglitazone
b. Gliclazide
c. Dulaglutide
d. Glargine
The correct answer is: Dulaglutide
Which of the following T2DM patients will benefit the most in the initiation of insulin therapy? (HPIM C397 p 2868)
a. 40/M with waist circumference of 95 cm
b. 45/F with HbA1c of 8.0 on metformin monotherapy
c. 50/M with FBS of 190 mg/dL not yet on any meds
d. 55/F with tuberculosis-related cachexia
The correct answer is: 55/F with tuberculosis-related cachexia
A 50/M with T2DM was rushed in the ER due to severe abdominal pain and vomiting. Blood glucose was 300 mg/dL with an arterial pH of 7.2 and a serum bicarbonate of 12 mEq/L. Serum creatine was 250 mmol/L, sodium was 122, chloride was 79 and potassium was 3.0 mEq/L. Which of the following management measures is the most appropriate for the patient’s condition? (HPIM C397 p2871 table 397-8).
a. Administer short-acting regular insulin IV (0.1 units/kg) bolus then 0.1 units/kg/hr by infusion.
b. Give 150 mEqs sodium bicarbonate bolus then give additional 250 mEqs by infusion over 24 hours.
c. Measure electrolytes and anion gap every 4 hours for first 24 hours.
d. Run 2-3 L of 0.45% saline at 10-20 mL/kg/hr over the first 1-3 hours.
The correct answer is: Measure electrolytes and anion gap every 4 hours for first 24 hours.
Which of the following statements best describe hyperglycemic hyperosmolar state? (HPIM C397 p2872)
a. HHS has a higher mortality rate than DKA
b. HHS patients are usually younger than DKA patients
c. Fluid losses are less pronounced in HHS compared to in DKA
d. Mental status changes are less seen in HHS compared to in DKA
The correct answer is: HHS has a higher mortality rate than DKA
A 56/M with T2DM was admitted in the ICU due to acute respiratory failure from hospital acquired pneumonia. His CBGs have been ranging from 200 – 300 mg/dL. Which of the following glycemic-lowering agents is most appropriate for him? (HPIM C397 p2873)
a. Insulin glulisine as subcutaneous boluses
b. Regular insulin as intravenous infusion
c. Insulin apidra as intravenous boluses
d. Insulin glargine as single subcutaneous bolus
The correct answer is: Regular insulin as intravenous infusion
A 42/F with T2DM with a BMI of 30 was admitted in the hospital due to acute pyelonephritis. She is currently afebrile with BP of 120/80. She is currently on insulin glargine 6 units SC injected at night and regular insulin 6 units pre-meals. Her current pre-lunch CBG is 280 mg/dL. Based on ADA recommendations, which of the following regimens will best address her hyperglycemia immediately? (HPIM C397 p2873)
a. Increase insulin glargine to 8 units pre-bedtime
b. Give regular insulin 8 units SC pre-lunch
c. Add insulin glargine 10 units pre-breakfast
d. Give regular insulin 10 units SC pre-lunch
The correct answer is: Give regular insulin 10 units SC pre-lunch
A 28/M with T1DM and choledocholithiasis is about to undergo open cholecystectomy. Which of the following insulin regimens is the LEAST sufficient to address his glycemic control? (HPIM C397 p2874)
a. Regular insulin via insulin pump
b. Regular insulin via IV infusion
c. Regular insulin via multiple SC boluses
d. Insulin detemir via single dose SC
The correct answer is: Regular insulin via multiple SC boluses
According to current recommendations, screening for gestational diabetes mellitus occurs during between what ages of gestation? (HPIM C397 p2874)
a. 12 and 16 weeks
b. 16 and 20 weeks
c. 20 and 24 weeks
d. 24 and 28 weeks
The correct answer is: 24 and 28 weeks
Which of the following statements is consistent with the findings of the DCCT and UKPDS with regards to glycemic control and the development of DM complications? (HPIM C398 p2875-2876)
a. There is strong evidence that chronic hyperglycemia leads to micro- and macrovascular complications.
b. There is a positive impact of a period of improved glycemic control on later disease.
c. The beneficial effects of glycemic control were greater than the beneficial effects of BP control.
d. The benefits of improvement in glycemic control were seen at HbA1c levels ≥ 9%
The correct answer is: There is a positive impact of a period of improved glycemic control on later disease.
A 45/M newly diagnosed with T2DM had his 1st positive urinary albumin test. Which of the following is the most appropriate action to take in managing his diabetic nephropathy? (HPIM C398 p2878 fig 398-4)
a. Repeat albuminuria test after 3 months.
b. Repeat albuminuria test after 12 months.
c. Begin treatment of nephropathy immediately.
d. Begin treatment of nephropathy once he has 3 positive albuminuria tests.
The correct answer is: Repeat albuminuria test after 3 months.
Which of the following statements best describe the most common form of diabetic neuropathy? (HPIM C398 p2879)
a. Pain involves the lower extremities, is usually absent at rest and worsens at night.
b. There is hyperhidrosis of the upper extremities and anhidrosis of the lower extremities.
c. Involvement of the third cranial nerve is most common and is heralded by diplopia.
d. There is loss of ankle deep-tendon reflexes and foot drop.
The correct answer is: There is loss of ankle deep-tendon reflexes and foot drop.
What is the most common pattern of dyslipidemia seen in diabetes mellitus? (HPIM C398 p2881)
a. High triglyceride, normal HDL, high LDL
b. High triglyceride, low HDL, normal LDL
c. Normal triglyceride, low HDL, high LDL
d. Normal triglyceride, normal HDL, high LDL
The correct answer is: High triglyceride, low HDL, normal LDL
A 33/M known diabetic was rushed into the ER due to 4-day history of fever associated with severe pain, foul-smelling discharge and hearing loss on her right ear. Which of the following organisms is the most common etiologic agent for her condition? (HPIM C398 p2882)
a. Candida albicans
b. Staphylococcus epidermidis
c. Pseudomonas aeruginosa
d. Staphylococcus aureus
The correct answer is: Pseudomonas aeruginosa
A 45/M T2DM patient complained of frequent light headedness, diaphoresis and palpitations. His CBGs ranges from 45-80 mg/dL/ His workup revealed a 1.0 cm pancreatic head mass on abdominal CT scan. Which of the following pathophysiologic features best explain his symptoms in correlation with his disease? (HPIM C399 p2887)
a. Failure of insulin secretion to fall during hypoglycemia
b. Overproduction of an incomplete form of insulin growth factor II
c. Impaired gluconeogenesis and low gluconeogenic precursors
d. Combined deficiency of glucagon and epinephrine
The correct answer is: Failure of insulin secretion to fall during hypoglycemia
A 20/M presents in the ER due to a 2 day-history of severe abdominal pain and vomiting. Pertinent lab findings include a markedly elevated triglyceride level at 1000 mg/dL with slightly elevated LDL and cholesterol levels. Physical exam revealed small, yellowish-white papules on the back. Which of the following conditions does the patient most likely has? (HPIM C400 p2894)
a. Familial Combined Hyperlipidemia
b. Familal Dysbetalipoproteineima
c. Familial Hypercholesterolemia
d. Familial Chylomicronemia
The correct answer is: Familial Chylomicronemia
It is important to intervene in patients with fasting triglyceride levels of >500 mg/dL in order to reduce the risk of developing what particular disease? (HPIM C400 p2901)
a. Acute stroke
b. Acute myocardial infarction
c. Acute pancreatitis
d. Acute ischemic hepatitis
The correct answer is: Acute pancreatitis
What is the drug of choice for a diabetic 30/F presenting with a triglyceride level of 600 mg/dL despite active lifestyle management? (HPIM C400 p2901)
a. Atorvastatin
b. Cholestyramine
c. Ezetemibe
d. Omega-3 FA
The correct answer is: Omega-3 FA
The most common pituitary hormone-secreting adenoma originates from which of the following anterior pituitary cell? (HPIM C373 P2674 table 373-3)
a. Corticotrope
b. Gonadotrope
c. Lactotrope
d. Somatotrope
In DECREASING ORDER of frequency
Hyperprolactinemia is the most common pituitary hormone hypersecretion syndrome in both men and women
The correct answer is: Lactotrope
A 22/M presented with prognathism and increased hand and foot size. Pertinent workup showed a large pituitary adenoma on cranial CT scan with contrast. Despite undergoing transsphenoidal surgery, his IGF-I levels remain elevated. Which of the following drugs can be added next as adjuvant treatment? (HPIM C373 p2680 fig. 373-5)
a. Octreotide
b. Pegvisomant
c. Bromocriptine
d. Mitotane
Patient has classic signs of ACROMEGALY
Somatostatin analogues are used as adjuvant treatment for:
• preoperative shrinkage of large invasive macroadenomas
• immediate relief of debilitating symptoms and reduction of GH hypersecretion
• in frail patients experiencing morbidity
• in patients who decline surgery
• when surgery fails
The correct answer is: Octreotide
Which of the following characteristics about ACTH-secreting pituitary tumors best differentiate it from ectopic ACTH secretion? (HPIM C373 p2681 table 373-8)
a. 24 hour urine free cortisol is elevated
b. Cortisol is <5 ug/dL after high-dose dexamethasone suppression
c. Associated with pigmentation and rapid onset of clinical features
d. Basal inferior petrosal : peripheral vein ACTH ratio is <2
24 hr urine free cortisol is elevated in both
High dose Dexa suppression test will be able to inhibit cortisol production in ACTH-dependent pituitary tumors via the feedback mechanism but has NO EFFECT on ECTOPIC ACTH sources
Rapid onset of symptoms and pigmentation are associated with ECTOPIC ACTH secretion
Basal inferior petrosal : peripheral vein ACTH ratio of <2 is consistent with ECTOPIC ACTH secretion
The correct answer is: Cortisol is <5 ug/dL after high-dose dexamethasone suppression
Prophylactic radiation therapy may be indicated to prevent the development of what syndrome after adrenalectomy in the setting of residual corticotrope adenoma? (HPIM C373 p2682)
a. Albright syndrome
b. Kallmann syndrome
c. Nelson syndrome
d. Wolfram syndrome
NELSON’S SYNDROME
A disorder characterized by rapid pituitary tumor enlargement and increased pigmentation secondary to high ACTH levels.
Prophylactic radiation therapy may be indicated to prevent the development of Nelson’s syndrome after adrenalectomy.
The correct answer is: Nelson syndrome
Which of the following statements is true regarding non-functioning pituitary adenomas? (HPIM C373 p2682)
a. They are the most common type of pituitary adenoma.
b. They are usually microadenomas at the time of diagnosis.
c. Most clinically non-functioning adenomas originate from lactotrope cells.
d. They are responsive to treatment with dopamine agonists.
NON-FUNCTIONING PITUITARY ADENOMAS
They are the most common type of pituitary adenomas
They are usually MACROADENOMAS at the time of diagnosis because clinical features are not apparent until mass effect occurs
Based on immunohistochemistry, most clinically nonfunctioning adenomas can be shown to originate from gonadotrope cells.
It is important to distinguish this circumstance from true prolactinomas, as nonfunctioning tumors do not shrink in response to treatment with dopamine agonists
The correct answer is: They are the most common type of pituitary adenoma.
Which of the following DOES NOT stimulate Vasopressin (AVP) secretion from the neurohypophysis? (HPIM C374 p2684)
a. Smoking
b. Hypotension
c. Nausea
d. Pain
VASOPRESSIN SECRETION Can be stimulated by the ff: • Hyperosmolarity (280 mosm/L) • Hypotension (10-20% decrease in BP) • Nausea (very potent – can cause 50-100 fold rise in AVP) • Acute hypoglycemia • Glucocorticoid deficiency • Smoking
There is no evidence that pain or other noxious stresses have any effect on AVP unless they elicit a vasovagal reaction with its associated nausea and hypotension
The correct answer is: Pain
A 30/M patient presents in the ICU with progressive decrease in sensorium. He underwent cranial surgery for head trauma 2 days prior. Pertinent workup revealed a serum sodium of 168 mmol/L. Average 24 hour urine output for the past 2 days was 4000 mL. Which of the following findings will best point to his likely diagnosis? (HPIM C374 p2687 fig 374-4)
a. Urine osmolarity of <300 mosm/L
b. Plasma AVP <1 pg/mL
c. No pituitary bright spot on MRI
d. Plasma osmolarity of >300 mosm/L
Acute hypernatremia and increased volume of urine in the setting of post-cranial surgery is highly suggestive of post-op pituitary diabetes insipidus
Urine osmolarity of <300 mosm/L is present in pituitary DI, primary polydipsia and nephrogenic DI
Plasma AVP <1 pg/mL is present in both primary polydipsia and pituitary DI
The pituitary bright spot is almost always absent or abnormally small in patients with pituitary DI
Plasma osmolarity of >300 can be present in both DI and non-DI etiologies
The correct answer is: No pituitary bright spot on MRI
A 60/F with squamous cell lung CA stage IV is referred for an incidental finding of low serum sodium (125 mEq/L). Patient denies having nausea or vomiting. Her BP was 120/80 with clear breath sounds and no edema on PE. Which of the following strategies is best suited to correct her hyponatremia? (HPIM C374 p2690-2691)
a. Give 0.05 mL/kg/min hypertonic saline to target sodium of 130 mEq/L
b. Give 1 mL/kg/hr plain saline to target sodium of 130 mEq/L
c. Give sodium chloride 1g/tab 3x a day
d. Give tolvaptan 15 mg/tab 1x a day
HYPONATREMIA TREATMENT
Patient most likely has Chronic Hyponatremia secondary to SIADH from lung CA
Patient is euvolemic and asymptomatic
Hyponatremia in this case should be corrected more gradually to avoid osmotic demyelination syndrome
This can be achieved by restricting total fluid intake to less than the sum of urinary and insensible losses. This regimen is often hard to adhere to.
It is often necessary to add a treatment that increases urinary water excretion. The oral AVP2 antagonist, tolvaptan, is best suited for this purpose.
The correct answer is: Give tolvaptan 15 mg/tab 1x a day
Which of the following is a specific feature of Cushing’s syndrome? (HPIM C379 p2725)
a. Buffalo hump
b. Proximal myopathy
c. Facial plethora
d. Hirsutism
A diagnosis of Cushing’s should be considered when several clinical features are found in the same patient, in particular when
more specific features are found. These include
- fragility of the skin, with easy bruising
- broad (>1 cm), purplish striae
- signs of proximal myopathy, which becomes most obvious when trying to stand up from a chair without the use of hands or when climbing stairs
The correct answer is: Proximal myopathy
A 35/M presents with consistent home BPs of 160-170/100-110 despite compliance with telmisartan. Pertinent labs revealed a serum potassium of 3.0 mEq/L. Which of the following is the most practical strategy to observe in preparation for further workup for the cause of his hypertension? (HPIM C379 p2729-2730 table 379-4)
a. Order for plasma renin and aldosterone levels right away
b. Stop telmisartan at least 2 weeks prior to ARR measurement
c. Stop telmisartan and shift to carvedilol 4 weeks prior to ARR measurement
d. Continue telmisartan and correct hypokalemia prior to ARR measurement
DIAGNOSTIC SCREENING FOR MINERALOCORTICOID EXCESS
The accepted screening test is concurrent measurement of plasma renin and aldosterone with subsequent calculation of the aldosterone-renin ratio (ARR)
Serum potassium should be normalized prior to testing
Stopping antihypertensive medication can be cumbersome, particularly in patients with severe hypertension.
For practical purposes, in the first instance the patient can remain on the usual antihypertensive medications, with the exception that MR antagonists need to be ceased at least 4 weeks prior to ARR measurement.
Carvedilol can falsely increase ARR
The correct answer is: Continue telmisartan and correct hypokalemia prior to ARR measurement
Which of the following statements is true regarding diagnostic workup for adrenal incidentalomas? (HPIM C379 p2731)
a. MRI with GAD is the procedure of choice for imaging the adrenal glands.
b. FNA or CT-guided biopsy of an adrenal mass is rarely indicated.
c. Tumor density can reliably differentiate adrenal adenomas from carcinomas
d. Tumors >4 cm are more likely malignant with a 90% specificity
DIAGNOSIS OF INCIDENTALOMAS
Unenhanced CT is the procedure of choice for imaging the adrenal glands
Size alone is of poor predictive value, with only 80% sensitivity and 60% specificity for the differentiation of benign from malignant masses when using a 4-cm cut-off
Tumor density on CT is of additional diagnostic value as many adrenocortical adenomas have low attenuation values. However, many of them also present with higher HU
FNA or CT-guided biopsy of an adrenal mass is rarely indicated
• FNA of pheochromocytoma can cause hypertensive crisis
• FNA of adrenocortical carcinoma can cause needle track metastasis
• Should only be considered in a patient with nonadrenal malignancy and a newly detected adrenal mass, after ruling out pheochromocytoma and if the outcome will influence therapeutic management
The correct answer is: FNA or CT-guided biopsy of an adrenal mass is rarely indicated.
Which of the following is the most common cause of primary adrenal insufficiency? (HPIM C379 p2733)
a. Autoimmune adrenalitis
b. Adrenal hemorrhage
c. Congenital adrenal hyperplasia
d. Tuberculous adrenalitis
PRIMARY ADRENAL INSUFFICIENCY
Primary adrenal insufficiency is most commonly caused by autoimmune adrenalitis.
Isolated autoimmune adrenalitis accounts for 30–40%, whereas 60–70% develop adrenal insufficiency as part of autoimmune polyglandular syndromes (APSs)
Rarer causes of adrenal insufficiency involve destruction of the adrenal glands as a consequence of infection, hemorrhage, or infiltration.
Tuberculous adrenalitis is still a frequent cause of disease in developing countries.
The correct answer is: Autoimmune adrenalitis
Which of the following features present in primary adrenal insufficiency best distinguish it from secondary adrenal insufficiency? (HPIM C379 p2734-2735)
a. Alabaster-colored skin
b. Hyponatremia
c. Hyperreninemia
d. Low blood pressure
PRIMARY ADRENAL INSUFFICIENCY
Characterized by the loss of both glucocorticoid and mineralocorticoid secretion
A distinguishing feature of primary adrenal insufficiency is hyperpigmentation, which is caused by excess ACTH stimulation of
melanocytes.
Hyponatremia can be present in both mineralocorticoid deficiency and in secondary adrenal insufficiency due to diminished inhibition of ADH release by cortisol.
Increased plasma renin will confirm presence of mineralocorticoid deficiency
Low BP and postural hypotension can be present in both
The correct answer is: Hyperreninemia
A 20-year old patient is referred at the OPD due to gynecomastia. Physical assessment revealed a male appearance with tall stature and small testes. Hormonal workup revealed elevated LH, FSH and estradiol and low testosterone levels. Semen analysis reveals azoospermia. Which of the following is the patient’s most likely chromosomal sex? (HPIM C383 p2762-2763 table 383-3)
a. 45,X/46,XX
b. 45,X/46,XY
c. 46,XX/46,XY
d. 46,XY/47,XXY
The correct answer is: 46,XY/47,XXY
Which of the following enzymes is deficient in the most common form of congenital adrenal hyperplasia? (HPIM C383 p2767)
a. 21-hydroxylase
b. 17α -hydroxylase
c. 11-hydroxylase
d. 3β-hydroxysteroid dehydrogenase
CONGENITAL ADRENAL HYPERPLASIA
The classic form of 21-hydroxylase deficiency (21-OHD) is the most common cause of CAH
The salt-wasting form of 21-OHD results from severe combined glucocorticoid and mineralocorticoid deficiency.
Females with classic simple virilizing form of 21-OHD present with genital ambiguity. They have impaired cortisol biosynthesis but do not have salt loss.
Patients with non-classic 21-OHD produce normal amounts of cortisol and aldosterone but at the expense of producing excess androgens.
The correct answer is: 21-hydroxylase
Which of the following hormones is necessary for the masculinization of the urogenital sinus and genital tubercle? (HPIM C384 p2772)
a. 5α dihydrotestosterone
b. Androsterone
c. Androstanedione
d. Testosterone
The conversion of testosterone to DHT is necessary for the masculinization of the urogenital sinus and genital tubercle.
The correct answer is: 5α dihydrotestosterone
A 28/F with previously normal menses consults for amenorrhea of 4 months duration. An extensive workup revealed no uterine tract abnormalities and negative pregnancy test. Hormone levels revealed normal prolactin and testosterone levels with increased LH and FSH levels. Which of the following is the most likely cause of her amenorrhea? (HPIM C386 p2796 fig 386-2)
a. Hypothalamic amenorrhea
b. Idiopathic hypogonadotropic hypogonadism
c. Primary ovarian insufficiency
d. Polycystic ovarian syndrome
The correct answer is: Primary ovarian insufficiency
According to the Women’s Health Initiative Estrogen-Progestin and Estrogen-Alone Trials, estrogen-progestin postmenopausal hormone therapy causes a definite increase in risk in the incidence of which of the following diseases? (HPIM C388 p2805 table 388-1)
a. Coronary heart disease
b. Ovarian cancer
c. Pulmonary embolism
d. Endometrial cancer
The correct answer is: Pulmonary embolism
Which of the following is an absolute contraindication to starting oral contraceptives? (HPIM C388 p2815 table 389-2)
a. Post-bariatric surgery
b. Controlled Hypertension
c. Women receiving anticonvulsant therapy
d. Systemic Lupus Erythematosus
The correct answer is: Systemic Lupus Erythematosus
Which of the following best describes very low-calorie diets (VLCDs)? (HPIM C395 p 2845)
a. It typically supplies ≤800 kcal per day with 50-80 g of protein
b. It is indicated for well-motivated individuals with a BMI of ≥25 kg/m2 who have failed at more conservative approaches to weight loss.
c. Its primary purpose is to promote a significant weight loss over a 6- to 12-month period.
d. It can lead to increased risk of gallstone formation that is not reduced with ursodeoxycholic acid prophylaxis.
VERY LOW-CALORIE DIETS (VLCDs)
The primary purpose of a VLCD is to promote a rapid and significant (13- to 23-kg) short-term weight loss over a 3- to 6-month period.
The proprietary formulas designed for this purpose typically supply ≤800 kcal, 50–80 g of protein, and 100% of the recommended daily intake for vitamins and minerals
indications include the involvement of well-motivated individuals who are
• moderately to severely obese (BMI, >30 kg/m2)
• have failed at more conservative approaches to weight loss
• have a medical condition that would be immediately improved with rapid weight loss
The risk of gallstone formation increases exponentially at rates of weight loss >1.5 kg/week
Prophylaxis against gallstone formation with UDCA 600 mg/d is effective in reducing this risk.
The correct answer is: It typically supplies ≤800 kcal per day with 50-80 g of protein
A 40/M with T2DM and hypertriglyceridemia has a BMI of 35. What would be the best approach for the treatment of his obesity? (HPIM C395 p 2846 table 395-4)
a. Advise to decrease daily calorie intake by 750 kcal/day
b. Encourage to engage in 75 minutes/week of vigorous-intensity aerobic physical activity
c. Start phentermine/topiramate and orlistat
d. Refer for bariatric surgery
Bariatric surgery can be considered for patients with
• severe obesity (BMI, ≥40 kg/m2) OR
• for those with moderate obesity (BMI, ≥35 kg/m2) associated with a serious medical condition
The correct answer is: Refer for bariatric surgery
Which of the following statements is true regarding the criteria for the diagnosis of diabetes mellitus? (HPIM C397 p 2852 table 396-2)
a. The OGTT is the most reliable test for identifying DM in asymptomatic individuals.
b. An individual with a HbA1c of 6.5 during his first set of tests is diagnostic of DM.
c. The current criteria allow for the diagnosis of DM to be withdrawn when glucose tolerance becomes normal.
d. Race and ethnicity have little impact in the reliability of HbA1c since it is standardized.
The current criteria for the diagnosis of DM emphasize the HbA1c or the FPG as the most reliable and convenient tests for identifying DM in asymptomatic individuals.
An OGTT, although a valid means for diagnosing DM, is not often used in routine clinical care with the exception of pregnancy care and screening for gestational diabetes.
Abnormalities on screening tests for diabetes should be repeated before making a definitive diagnosis of DM, unless acute metabolic derangements or a markedly elevated plasma glucose are present
These criteria also allow for the diagnosis of DM to be withdrawn in situations when the glucose intolerance reverts to normal
It is important to note that race and ethnicity may impact the reliability of HbA1c levels. For example, African Americans have a higher HbA1c value compared to non-Hispanic whites with a similar level of glycemia.
The correct answer is: The current criteria allow for the diagnosis of DM to be withdrawn when glucose tolerance becomes normal.
At what age does ADA recommend initiating screening for all individuals? (HPIM C397 p2853)
a. 35
b. 40
c. 45
d. 50
ADA RECOMMENDATIONS FOR SCREENING
The ADA recommends screening all individuals aged >45 years every 3 years and screening individuals at an earlier age if they are overweight (BMI >25 kg/m2 or ethnically relevant definition for overweight) and have one additional risk factor for diabetes
The correct answer is: 45
A 30/F has a BMI of 27 kg/m2. Which among the following findings in the patient will prompt screening for Type 2 DM? (HPIM C397 p2853 table 396-3)
a. Hemoglobin A1c of 5.5%
b. Blood pressure of 140/90
c. 2 hour post prandial glucose of 130 mg/dL
d. Triglyceride level of 200 mg/dL
ADA RECOMMENDATIONS FOR SCREENING
The ADA recommends screening all individuals aged >45 years every 3 years and screening individuals at an earlier age if they are overweight (BMI >25 kg/m2 or ethnically relevant definition for overweight) and have one additional risk factor for diabetes
The correct answer is: Blood pressure of 140/90
Which of the following best describes the genetic mechanisms behind diabetes mellitus? (HPIM C396 p2855-2856)
a. Most individuals with Type 1 DM do not have a first-degree relative with this disorder.
b. The concordance of Type 2 DM in identical twins is between 40 and 60%.
c. Type 1 DM is polygenic and multifactorial because environmental factors (e.g. obesity) also modulate the phenotype.
d. The risk of developing Type 2 DM in relatives of individuals with the disease is relatively low.
GENETIC CONSIDERATIONS OF DM
Although the risk of developing type 1 DM is increased tenfold in relatives of individuals with the disease, the risk is relatively low: 3–4% if the parent has type 1 DM and 5–15% in a sibling .
Hence, most individuals with type 1 DM (75%) do not have a first-degree relative with this disorder
Type 2 DM has a strong genetic component. The concordance of type 2 DM in identical twins is between 70 and 90%
Individuals with a parent with type 2 DM have an increased risk of diabetes; if both parents have type 2 DM, the risk approaches 40%
Type 2 DM is polygenic and multifactorial, because in addition to genetic susceptibility, environmental factors (such as obesity, poor nutrition, and physical inactivity) modulate the phenotype
The correct answer is: Most individuals with Type 1 DM do not have a first-degree relative with this disorder.
According to ADA, which of the following drugs can be considered to prevent or delay onset of T2DM in individuals with both IFG and IGT and are at a very high risk for progression to diabetes? (HPIM C396 p2857)
a. Acarbose
b. Metformin
c. Orlistat
d. Pioglitazone
DM PREVENTION
A number of agents, including a-glucosidase inhibitors, metformin, thiazolidinediones, GLP-1 receptor pathway modifiers, and orlistat, prevent or delay type 2 DM but are not approved by the Food and Drug Administration for this purpose.
Pharmacologic therapy for individuals with prediabetes is currently controversial because its cost-effectiveness and safety profile are not known.
The ADA suggests that metformin be considered in individuals with both IFG and IGT who are at very high risk for progression to diabetes (age <60 years, BMI ≥35 kg/m2, and women with a history of GDM)
The correct answer is: Metformin
Which of the following monogenic forms of DM will respond well to sulfonylurea treatment? (HPIM C396 p2858)
a. MODY 1
b. MODY 2
c. MODY 3
d. MODY 4
MONOGENIC FORMS OF DM
MODY 1, MODY 3, and MODY 5 are caused by mutations in hepatocyte nuclear transcription factor (HNF) 4a, HNF-1a, and HNF-1B, respectively.
Individuals with an HNF-1a mutation (MODY 3) have a progressive decline in glycemic control but may respond to sulfonylureas.
Individuals with MODY 2, the result of mutations in the glucokinase gene, have mild-to-moderate, but stable hyperglycemia that does not respond to oral hypoglycemic agents
MODY 4 is a rare variant caused by mutations in pancreatic and duodenal homeobox 1, a transcription factor that regulates pancreatic development and insulin gene transcription
The correct answer is: MODY 3
Which of the following clinical characteristics will be most consistent with a patient with new-onset Type 2 DM? (HPIM C396 p2858)
a. Elevated blood pressure
b. Propensity to develop ketoacidosis
c. Increased risk to develop autoimmune disorders
d. Lean body habitus
The correct answer is: Elevated blood pressure
Which of the following screening procedures is part of the guidelines for comprehensive diabetes care for all individuals with DM? (HPIM C397 p2860 table 397-1)
a. Lipid profile testing every 6 months
b. Urine albumin testing every 4 months
c. Blood pressure assessment every 3 months
d. Foot examination by the patient monthly
Lipids annually
Diabetes-related kidney disease testing annually
Blood pressure assessment quarterly
Foot examination
• 1-2 times/year by provider
• Daily by patient
The correct answer is: Blood pressure assessment every 3 months
A 36/M with Type 1 DM on insulin glargine and glulisine is an active jogger who experiences frequent episodes of light headedness during his regular routine. What would be the best advise to give him to prevent these episodes? (HPIM C397 p2861)
a. Delay jogging if blood glucose is >300 mg/dL and ketones are present.
b. Eat bread before jogging if blood glucose is <150 mg/dL.
c. Decrease insulin dose before and maintain insulin dose after jogging.
d. Inject insulin into a non-exercising area.
AVOIDANCE OF EXERCISE-RELATED HYPO/HYPERGLYCEMIA
• monitor blood glucose before, during, and after exercise
• delay exercise if blood glucose is >14 mmol/L (250 mg/dL) and ketones are present
• If the blood glucose is <5.6 mmol/L (100 mg/dL), ingest carbohydrate before exercising
• Monitor glucose during exercise and ingest carbohydrate to prevent hypoglycemia
• Decrease insulin doses (based on previous experience) before and after exercise and inject insulin into a non-exercising area
• Learn individual glucose responses to different types of exercise
The correct answer is: Inject insulin into a non-exercising area.
Which of the following statements is true regarding the properties of glycated hemoglobin? (HPIM C397 p 2862).
a. It detects glycemic variability like self-monitoring of blood glucose
b. Glycemic level in the preceding month contributes about 70% to the HbA1c value.
c. Recent intercurrent illnesses can impact HbA1c.
d. Nocturnal hyperglycemia will be reflected in the HbA1c.
ASSESSMENT OF LONG TERM GLYCEMIC CONTROL
Measurement of glycated hemoglobin (HbA1c) is the standard method for assessing long-term glycemic control.
Glycemic level in the preceding month contributes about 50% to the HbA1c value
As the primary predictor of long-term complications of DM, the HbA1c should mirror, to a certain extent, the short-term measurements of SMBG
These two measurements are complementary in that recent intercurrent illnesses may impact the SMBG measurements but not the HbA1c
Likewise, postprandial and nocturnal hyperglycemia may not be detected by the SMBG of fasting and preprandial capillary plasma glucose but will be reflected in the HbA1c
The HbA1c is an “average” and thus does not detect glycemic variability in the way SMBG and CGM can.
The correct answer is: Nocturnal hyperglycemia will be reflected in the HbA1c.
Which of the following statements most accurately reflect frequently used insulin regimens in Type 1 DM? (HPIM C397 p 2864).
a. In general, Type 1 DM patients require 1-2 units/kg per day of insulin.
b. A common insulin-to-carbohydrate ratio is 1 unit per 15 g of carbohydrate.
c. Insulin is given as multiple doses with 70% given as basal insulin.
d. Supplemental insulin is given at 2 units of insulin for every 50 mg/dL over glucose target.
TYPE 1 DM INSULIN REGIMENS
In general, individuals with type 1 DM require 0.4–1 units/kg per day of insulin divided into multiple doses, with ~50% of the insulin given as basal insulin
To determine the meal component of the preprandial insulin dose, the patient uses an insulin-to carbohydrate ratio
• a common ratio for type 1 DM is 1 unit/10–15 g of carbohydrate, but this must be determined for each individual
To this insulin, dose is added the supplemental or correcting insulin based on the preprandial blood glucose (one formula uses 1 unit of insulin for every 2.7 mmol/L [50 mg/dL] over the preprandial glucose target
An alternative multiple-component insulin regimen consists of bedtime NPH insulin, a small dose of NPH insulin at breakfast (20–30% of bedtime dose), and preprandial short-acting insulin
The correct answer is: A common insulin-to-carbohydrate ratio is 1 unit per 15 g of carbohydrate.
A 50/F with newly diagnosed T2DM and CHF was initially prescribed with metformin and was advised medical nutrition therapy. After 3 months, her repeat labs showed an increase in HBA1c from 8.5 to 9.0. Her eGFR decreased from 50 mL/min to 35 mL/min. After reducing her metformin dose, which of the following is the most suitable drug to be added to her current regimen? (HPIM C397 p2866-2869)
a. Empagliflozin
b. Glargine
c. Pioglitazone
d. Vildagliptin
Patient has rise in HbA1c on metformin monotherapy as well as reduction in eGFR
Next step is to add a second agent, usually an oral antihyperglycemic in combination with metformin
Patient can still use metformin but in reduced dose (eGFR <35)
Empagliflozin cannot be initiated at eGFR <45
Glargine can be added only if dual OHAs cannot control HbA1c after next reassessment
Pioglitazone is contraindicated in this patient due to her CHF
Vildagliptin is the best choice because it can be given without renal dose adjustment
The correct answer is: Vildagliptin
A 70/F with T2DM on metformin complains of frequent nausea, diarrhea and anorexia. Since she is not able to eat properly, she has intermittent episodes of light headedness and blurring of vision. Her current HBA1c is 8.5. Which of the following glucose-lowering agents is best suited for her in place of metformin? (HPIM C397 p 2866 table 397-5)
a. Dapagliflozin
b. Miglitol
c. Repaglinide
d. Glimepiride
Patient cannot tolerate Metformin (nausea and vomiting) and has hypoglycemic episodes
Miglitol and repaglinide are nonsulfonylurea secretagogues, while glimepiride is a sulfonylurea. All of them can cause hypoglycemia which the patient is already having due to poor appetite
SGLT2 inhibitors like dapagliflozin do not cause hypoglycemia and is best suited for our patient among the choices
The correct answer is: Dapagliflozin
