Endocrine

Question 1

Endocrine Key points

Answer 1

Best screening test for cortisol excess is 8am cortisol after dexamaethasone. Anytime we want to evaluate if there is excess, we try to suppress it. If we want to eval for too little of something westimulate it.

Question 2

Endocrine Key points

Answer 2

Post pituitary makes ADH and oxytocin

ADH regulates water at the kidney

ADH concentrates the urine and conserves water.

If deficient, this is central diabetes insipidus and more water is seen in urine. Suspect if polyuria over 2.5L of water a day.

Inability to concentrate urine

Use water deprivation test to confirm. Treat with DDAVP, then you see rapid increase in urine osms.

Question 3

Endocrine Key points

Answer 3

Nephrogenic DI

Usually related to meds like Lithium and hypercalcemia

Pee a lot more, get dehydrated

When you give DDAVP here there is no change in urine osms.

Treat with diuretics

Question 4

Endocrine Key points

Answer 4

Empty sella syndrome

Incidental, ignore if all systems are functioning

But you have to make sure it is not functional, checking prolactin and IGF-1 and cortisiol access

Question 5

Endocrine Key points

Answer 5

Prolactinoma

sx: increased proloactin decreases gnrh, and lh fsh, leads to amenorrhea, galactorrhea, in fertility impotence, hypogonadism,

dopamine shuts off prolactin

so treat with dopamine agonist (Cabergoline)

Question 6

Endocrine Key points

Answer 6

If concerned about acromegaly, check IGF-1.

Pay attention to enlarging features (heart, BMI, headaches, new DM, large hands, ),

RULE: If you go hypoglycemia, you increase GH.

Confirm with 75g glucose. You can also try suppress the GH with a glucose load and if the GH fails to be suppressed with glucose it is acromegaly. If you can stshut off the GH, it is not acromegaly

Treat with surgery

Question 7

Endocrine Key points

Answer 7

Pituitary apoplexy is when we have a pit tumor outgrow blood supply.

PRES: WORSE HA, n,v, field def

Dx: CT

Treat: GIVE Glucocorticoids
Surgery

Question 8

Endocrine Key points

Answer 8

Low TSH seen in Hyperthyroidism, High TSH seen in Hypothyroidism.

Order both TSH and T4 if you suspect a pituitary cause

Question 9

Endocrine Key points

Answer 9

Usually T4 and TSH are opposite! However if they are going the same direction t,(both low/normal) think Euthyroid sick syndrome

sick body cant convert t4 to t3. so it males the inactive t3 which is rT3.

Usually in this syndrome the TSH is low, T4 is low, t3 is low

Question 10

Endocrine Key points

Answer 10

Hypothyroid Causes:

Autoimmune (Hashimoto)- TPO antibodies- elevated TSH

Postpartum thyroiditis- treat with selenium

Meds can cause_ amio, lithium

sx: bradycardia, deleayed reflexes

Question 11

Endocrine Key points

Answer 11

All patients with TSH over 10 get treated for hypothyroidism, also those with a goiter or pregnant . TSH needs to be less than 2.5

If a nodule present, get US

Question 12

Endocrine Key points

Answer 12

recheck thyroid after 6 weeks

Answer 13

EMERGENCY
Mxyedema Coma

AMS, hypothermia, bradycardia, abnormal TSH

Treat with passive warming, IV T4 Thyrdoid, treat with steroids for adrenal infuffiency

treat with steroids first

look for xauses0 Infxn,

Question 14

Endocrine Key points

Answer 14

T4 is carried by TBG

Estrogen increases TBG

Weight affects dose needs of t4 (pregnancy,

Starting/stopping estrogen will affect thyroid hormone dose

Question 15

Endocrine Key points

Answer 15

Hyperthyroid0 wt loss, palpa, diarrhea, anxiety0 low tsh, increased t4
- Most common cause Graves- TSUI

Graves- clinical- bruits, orbital ossues

Thinking painful thyroiditis in someone with painfully thyroid and URI

toxic multinodular goiter- someome who had contrast recently

Exogenous- overwgight nurse0 low thyroglobulin level - taking too much t4 leads to low thyro glub

Question 16

Endocrine Key points

Answer 16

Treating hyperthyroidism

Beta Blockera_ (propanolol)- blocks t4 to t3 - treats symptoms\

For Graves- Methimazole is first line, then PTU use second ( can be used in 1st trimester)

Can use radioactive iodine- I131 therapy or last option is surgery

Question 17

Endocrine Key points

Answer 17

Radiation exposure of the thyroid during childhood is the strongest environmental risk factor for thyroid cancer, most commonly papillary cancer.

Follicular thyroid cancer is less common than papillary thyroid cancer, it tends to occur in older persons, and it rarely metastasizes to lymph nodes

Medullary thyroid cancer may be associated with several syndromes, including multiple endocrine neoplasia type 2A (MEN2A) (which may include pheochromocytoma and hyperparathyroidism), MEN2B (marfanoid habitus and mucosal ganglioneuromas), or familial medullary thyroid cancer

Question 18

Endocrine Key points

Answer 18

Liraglutide is an add-on therapy to metformin to achieve improvement in hemoglobin A1c level and weight loss.

However There are potential concerns for development of pancreatitis and medullary thyroid carcinoma with GLP-1 receptor agonists.

Question 19

Endocrine Key points

Answer 19

Empagliflozin, a sodium-glucose transporter-2 (SGLT2) inhibitor, may be added to metformin when the hemoglobin A1c remains above goal. SGLT2 inhibitor use improves glycemic control and induces weight loss, but it also increases the risk of genital mycotic infections. Empagliflozin should not be used in this patient because it may exacerbate her frequent vulvovaginal candidiasis infections.

Jardiance and fungal cooty infections

Question 20

Endocrine Key points

Answer 20

Glipizide associated with weight gain

Question 21

Endocrine Key points

Answer 21

The most common cause of primary adrenal insufficiency in the United States is autoimmune adrenalitis, and positive 21-hydroxylase antibodies are found in approximately 90% of those cases.

Cosyntropin stimulation testing is used to diagnose the presence of adrenal insufficiency, but it will not help determine the underlying cause.

Question 22

Endocrine

Answer 22

Antipsychotic agents cause hyperprolactinemia due to their antidopaminergic effect, which interrupts the inhibition of prolactin by dopamine; risperidone may raise the prolactin level above 200 ng/mL (200 μg/L).

When the prolactin level is only mildly elevated (<50 ng/mL [50 μg/L]), it may be reasonable to assume that hyperprolactinemia is a medication side effect. When significantly elevated (>100 ng/mL [100 μg/L]), either the medication needs to be withheld to further assess or a pituitary MRI obtained to evaluate for prolactinoma.

Question 23

Endocrine

Answer 23

Patients with primary adrenal failure require both glucocorticoid and mineralocorticoid replacement therapy.

She has primary adrenal insufficiency, which affects all layers of the adrenal cortex, and therefore she requires both glucocorticoid and mineralocorticoid (aldosterone) therapy.

Question 24

Endocrine

Answer 24

Serum alkaline phosphatase, a marker of increased bone turnover, should be measured after radiographic diagnosis of Paget disease of bone.

Can treat with bisphosphonates

Question 25

Endocrine

Answer 25

Subacute thyroiditis is an uncommon cause of thyrotoxicosis that presents following a viral upper respiratory tract infection and is distinguished by a tender or painful thyroid, suppressed thyroid-stimulating hormone, and elevated serum free thyroxine.

Nodular thyroid disease (toxic adenoma and multinodular goiter) is the next most common cause of thyrotoxicosis after Graves disease and is more commonly seen in older adults. This patient lacks palpable thyroid nodules on examination, which is usually seen with hyperthyroidism from nodular thyroid disease. In addition, neither Graves disease nor nodular thyroid disease cause thyroid pain.

Question 26

Endocrine

Answer 26

Potent antiresorptive drugs can cause severe hypocalcemia by impairing efflux of calcium from the skeleton in patients with vitamin D deficiency; it is important to assess vitamin D levels and correct deficiency before beginning treatment with an antiresorptive drug.

High baseline bone turnover and abrupt alteration in calcium flux between blood and bone are also features of hungry bone syndrome. However, this syndrome specifically occurs after parathyroidectomy for primary hyperparathyroidism. It is caused by rapid influx of calcium from the blood into the skeleton.

Question 27

Endocrine

Answer 27

Signs of androgen excess such as progressive hirsutism and virilization over a short period of time in female patients suggest the diagnosis of an androgen-producing adrenal or ovarian tumor.

A pelvic ultrasound is recommended as the first imaging study if testosterone is above 150 ng/dL (5.2 nmol/L). This patient’s testosterone level was only mildly elevated, but the DHEAS was quite elevated making a testosterone-producing ovarian tumor less likely than an adrenal tumor.

Question 28

Endocrine

Answer 28

Nonthyroidal illness syndrome (euthyroid sick syndrome) is characterized by reduced serum T3, low or low-normal serum T4, and normal or low (but detectable) serum TSH levels.

Question 29

Endocrine

Answer 29

Following adrenalectomy for Cushing syndrome, patients require daily glucocorticoid replacement therapy to allow recovery from prolonged suppression due to hypercortisolism; recovery of adrenal function may take up to 1 year or longer depending on the severity of Cushing syndrome.

fludrocortisone therapy is not required following adrenalectomy as mineralocorticoid secretion is not under ACTH control.

Question 30

Endocrine

Answer 30

Following adrenalectomy for Cushing syndrome, patients require daily glucocorticoid replacement therapy to allow recovery from prolonged suppression due to hypercortisolism; recovery of adrenal function may take up to 1 year or longer depending on the severity of Cushing syndrome.

fludrocortisone therapy is not required following adrenalectomy as mineralocorticoid secretion is not under ACTH control.

Question 31

Endocrine

Answer 31

In men with specific signs and symptoms of hypogonadism, measuring an 8 AM total testosterone level is indicated; if the testosterone level is low, a second 8 AM confirmatory testosterone level is measured.

Question 32

Endocrine

Answer 32

Graves disease: Treat with BB like propanolol and / Methimizazoine
Use PTU in 1st trimester and for stroem

Question 33

endocrine

Answer 33

Treat large toxic gotiers with ablation

Question 34

endocrine

Answer 34

For thyroid storm, this is one of the few times you want yo use PTU. Then use iodide, then BB for sx control, glucocorticoids.

Question 35

endocrine

Answer 35

Hypothyroid: Pregancy, and hypothyroidm will need to increased thyroid meds.

For hyperthyroid, goal is to keep a normal t4, use PTU

Question 36

Endocrine

Answer 36

Thyroid nodules, screen is high risk like radiation,

concerning features- solid with calcifications, irreg margins, fixed, hard, LAD, focal uptake,

• Check TSH, if low check do the uptake for toxic nodule
  if TSH normal or high. ultrasound thrpid

Bx with FINA if it has calcium, irreg borderd, size, PET +

Question 37

Endocrine

Answer 37

Any thyroidits will have low up take because the gland is being destryoed.

Graves will have high uptake

Question 38

Endocrine

Answer 38

ACTH acts on the adrenal mainly regulates cortisol

Renin- regulated aldosterone

DHEAS- regulates anrogens

Adrenal medulla- makes catecholamines

Question 39

Endocrine

Answer 39

Primary adrenal insuffiency, most connonly addisions, where there is high ACTh but it is unable to act on the adrenals due to automimune attack.

dx with ACTH stim test and you will see cortison fail to rise

Dex to treat

HIGH ACTH means hyperigmentation

Question 40

Endocrine

Answer 40

Treat pheochromocytoma wiith alpha blockers, like terazosin

Question 41

Endocrine

Answer 41

Make sure new adrenal incidentalolas are not functina;. check 1mg dex test and for pheo. If not functional then can monitor with imaging.

Question 42

Endocrine

Answer 42

To diagnose hypogonadism in men, you need an 8am testosterone that is low ON TWO OCCASIONS

If testosterone is low, measure LH, FSH, prolactin

Question 43

Endocrine

Answer 43

In chronic hypoparathyroidism, the goals of therapy are to eliminate symptoms while avoiding complications of therapy; monitoring urine calcium excretion is mandatory because hypercalciuria often limits therapy.

Question 44

endocrine

Answer 44

Once Cushing syndrome is confirmed, the next step in the diagnosis is to categorize Cushing syndrome into ACTH-dependent and ACTH-independent types, which in turn governs subsequent localization tests. A low serum ACTH level, as in this patient, indicates ACTH-independent Cushing syndrome.

Question 45

endocrine

Answer 45

For women with hypothyroidism adequately treated with levothyroxine before pregnancy, dosing can be empirically increased by 30% when pregnancy is confirmed.

Question 46

endocrine

Answer 46

Many medications cause falsely high levels of catecholamines or metanephrines including certain antidepressants that inhibit norepinephrine uptake; therefore discontinuation of these agents at least 2 weeks prior to testing for pheochromocytoma is recommended.

Question 47

endocrine

Answer 47

For low-risk osteoporotic women, treatment with antiresorptive therapy for 5 years is sufficient.

Trial Long-term Extension (FLEX) trial showed that continuing alendronate treatment for 10 years compared with stopping after 5 years resulted in a small decrease in the incidence of clinical vertebral fractures but not nonvertebral fractures

Question 48

endocrine

Answer 48

Oral contraceptive agents are first-line pharmacologic therapy for hirsutism, acne, and menstrual dysfunction unless fertility is desired in a patient with polycystic ovary syndrome.

The prolonged clinical course and absence of the more concerning findings of virilization also support the diagnosis of polycystic ovary syndrome. Given that this patient is most concerned about hirsutism and acne, oral contraceptive therapy is the first-line therapeutic agent. Oral contraceptive therapy suppresses gonadotropin secretion and resultant ovarian androgen production.

Question 48

endocrine

Answer 48

Oral contraceptive agents are first-line pharmacologic therapy for hirsutism, acne, and menstrual dysfunction unless fertility is desired in a patient with polycystic ovary syndrome.

The prolonged clinical course and absence of the more concerning findings of virilization also support the diagnosis of polycystic ovary syndrome. Given that this patient is most concerned about hirsutism and acne, oral contraceptive therapy is the first-line therapeutic agent. Oral contraceptive therapy suppresses gonadotropin secretion and resultant ovarian androgen production.

Question 49

endocrine

Answer 49

In patients with pituitary tumors, pituitary hypersecretion should be ruled out by biochemical testing.

When a pituitary tumor is incidentally noted, investigation must determine (1) whether it is causing a mass effect, (2) whether it is secreting excess hormones, and (3) whether it has a propensity to grow and cause problems in the future

all patients should be evaluated for hormone hyposecretion in order to identify and replace hormone deficiencies. Initial tests to evaluate for hormone deficiency should include measurement of 8 AM cortisol, thyroid-stimulating hormone (TSH), free (or total) thyroxine (T4), follicle stimulating hormone (FSH), testosterone in men and menstrual history in women (normal menstrual cycles eliminates the need to measure hormone levels). Prolactin and IGF-1 are measured to rule out pituitary hormone hypersecretion.

Question 50

endocrine

Answer 50

An α-receptor blockade with phenoxybenzamine or another α-blocker is required prior to adrenalectomy for pheochromocytoma to prevent potential hypertensive crisis during anesthesia induction and/or manipulation of the tumor.

Question 51

endocrine

Answer 51

Empagliflozin has been shown to reduce cardiovascular-related events and all-cause mortality in patients with type 2 diabetes mellitus and cardiovascular disease.

The dipeptidyl peptidase-4 (DPP-4) inhibitor, sitagliptin, could reduces systolic blood pressure and cause pancreatitis

liraglutide also has postmarketing reports of pancreatitis associated n

Question 52

Endocrine

Answer 52

After ruling out pregnancy, the initial laboratory evaluation in secondary amenorrhea includes measurement of follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels.

Question 53

Endocrine

Answer 53

To manage in-patient hyperglycemia, scheduled basal insulin or basal insulin plus correction insulin is appropriate for patients who are fasting or who have poor oral intake.

Question 54

Endocrine

Answer 54

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common complication of pituitary surgery that may occur 3 to 7 days following surgery; treatment with fluid restriction will prevent further reduction in sodium levels.

Question 55

Endocrine

Answer 55

Dopamine agonist therapy should be used to treat hyperprolactinemia in women with irregular periods who are trying to conceive.

Question 56

Endocrine

Answer 56

Primary hyperparathyroidism may be the first sign of multiple endocrine neoplasia syndrome 1 (MEN1) in persons with a family history of recurrent primary hyperparathyroidism and neuroendocrine tumors arising from the pancreas and tumors of the pituitary gland.

Question 57

Endocrine

Answer 57

An elevated 1,25-dihydroxyvitamin D level and suppressed parathyroid hormone is diagnostic of vitamin D-dependent hypercalcemia.

Question 58

Endocrine

Answer 58

Women with type 1 or type 2 diabetes mellitus who are planning pregnancy should be counseled on the risk of development or progression of diabetic retinopathy; rapid improvements in glycemic levels during pregnancy can temporarily worsen preexisting retinopathy.

Question 59

Endocrine

Answer 59

Oral bisphosphonates (alendronate) are recommended as first-line therapy in adult men and women on chronic glucocorticoid therapy with moderate to high fracture risk regardless of age.

Zoledronic acid is indicated for the treatment and prevention of glucocorticoid-induced osteoporosis in patients who cannot tolerate oral bisphosphonates.

Question 60

Endocrine

Answer 60

Signs and symptoms of a thyroid-stimulating hormone-secreting adenoma are those seen in hyperthyroidism, although laboratory evaluation reveals an elevated free thyroxine (T4) level with an inappropriately normal or elevated thyroid-stimulating hormone level.

Question 61

Endocrine

Answer 61

bisphosphonate can be considered for stopping after 5 years but
When administered subcutaneously twice yearly, denosumab suppresses bone resorption, increases bone density, and reduces the incidence of osteoporotic fractures in men and women; the effects of denosumab are not sustained when treatment is stopped.

Question 62

Endocrine

Answer 62

In fasting hospitalized patients with type 1 diabetes mellitus, the basal insulin dose should be decreased, the prandial insulin held to avoid hypoglycemia, and a correction insulin regimen should be added to help manage hyperglycemia.

Question 63

Endocrine

Answer 63

Biochemical testing for pheochromocytoma should be undertaken in all patients with an adrenal mass that is clearly not an adenoma, even in the absence of typical symptoms or hypertension.

Question 64

Endocrine

Answer 64

Initial testing for subclinical Cushing syndrome is a 1-mg overnight dexamethasone suppression test; a cortisol level greater than 5 µg/dL (138 nmol/L) is considered a positive test.

Question 65

Endocrine

Answer 65

When testing for cortisol excess in someone who works night shift, The 24-hour urine free cortisol test for Cushing syndrome is the best test because it is not impacted by either estrogen therapy or sleeping patterns.

Of note serum cortisol measurement is unreliable in this patient as she is on oral estrogen, which leads to an increase in cortisol binding proteins and subsequent elevation of serum total cortisol levels

Question 66

Endocrine

Answer 66

Gynecomastia can be an adverse effect of medications; spironolactone causes an imbalance between free estrogen and free androgen resulting in glandular breast tissue enlargement.

Question 67

Endocrine

Answer 67

Malabsorptive disorders (Like CELIAC) may decrease levothyroxine absorption resulting in higher than expected levothyroxine dose requirements.

Question 68

Endocrine

Answer 68

In women over the age of 35 years, an infertility evaluation is initiated after 6 months of unprotected intercourse; in women under the age of 35, an infertility evaluation is initiated after 1 year of regular unprotected intercourse.

Question 69

Endocrine

Answer 69

Chronic opioid use suppresses gonadotroph function, resulting in hypogonadotropic hypogonadism, which is increasingly recognized as a cause of secondary hypogonadism.

Question 70

Endocrine

Answer 70

A mixed-meal test consisting of the types of food that normally induce the hypoglycemia should be performed to determine the cause of postprandial hypoglycemia.

Postprandial hypoglycemia can develop 2 to 3 years after Roux-en-Y gastric bypass surgery.

Question 71

Endocrine

Answer 71

This patient has secondary adrenal insufficiency, and hydrocortisone is the most appropriate treatment.

An early morning (8 AM) serum cortisol of less than 3 μg/dL (82.8 nmol/L) is consistent with cortisol deficiency,

Fludrocortisone is needed only in primary adrenal insufficiency.

Question 72

Endocrine

Answer 72

Levothyroxine is the treatment of choice for thyroid hormone deficiency; for most younger adults without cardiac disease, a weight-based replacement dose of levothyroxine (1.6 µg/kg lean body weight) is recommended.

older adults (age 65 years and older) and patients with cardiovascular disease should be prescribed a lower initial dose (25-50 µg/day) due to the effects of thyroid hormone on myocardial oxygen demand.

Question 73

Endocrine

Answer 73

An adrenocorticotropic hormone (ACTH) measurement should be obtained once the diagnosis of Cushing syndrome is established to determine if it is ACTH dependent or ACTH independent.

Cushing disease is the term used to indicate excess cortisol production due to an ACTH-secreting pituitary adenoma. Cushing syndrome refers to hypercortisolism from any cause, exogenous or endogenous, ACTH-dependent or not.

At least two first-line tests should be diagnostically abnormal before the diagnosis is confirmed. Initial tests include the overnight low-dose dexamethasone suppression test, 24-hour urine free cortisol, and late-night salivary cortisol. The 24-hour urine free cortisol and late night salivary cortisol tests should be performed at least twice to ensure reproducibility of results.

Question 74

Endocrine

Answer 74

In patients receiving thyroxine replacement therapy, initiation of estrogen or raloxifene increases thyroxine-binding globulin levels whereas testosterone reduces thyroxine-binding globulin levels; in either situation a change in thyroxine dosage may be required.

Question 75

Estrogen

Answer 75

Alendronate, risedronate, zoledronic acid, and denosumab have been shown to reduce the risk for spine, hip, and nonvertebral fractures, and are generally well tolerated with low risk for serious adverse effects.

Denosumab is effective for prevention of vertebral fracture in postmenopausal women, yet it is expensive and, once started, should be continued indefinitely.

Question 76

Endocrine

Answer 76

Sulfonylureas stimulate insulin secretion, and they pose risk for hypoglycemia, especially drugs with long half-lives, such as glyburide, or in older persons.

Question 77

Endocrine

Answer 77

Spironolactone and eplerenone can significantly interfere with interpretation of the plasma aldosterone-plasma renin ratio (ARR) and therefore should be discontinued approximately 6 weeks prior to screening for primary aldosteronism.

Question 78

Endocrine

Answer 78

A hemoglobin A1c goal of 7.5% to 8% is recommended for older adults with complex medical history and significant comorbidities.

A hemoglobin A1c goal of 7.5% to 8% is recommended for older adults with complex medical history and significant comorbidities.

Question 79

Endocrine

Answer 79

Checkpoint inhibitors such as nivolumab, ipilimumab, and pembrolizumab have been associated with the development of hypophysitis with most patients presenting with the combination of headache, pituitary enlargement, and hypopituitarism.

Question 80

Endocrine

Answer 80

Adrenalectomy is recommended for incidental adrenal masses with radiologic features that suggest increased risk of an adrenal malignancy (size >4 cm, density ≥10 Hounsfield units, and absolute contrast washout <50% at 10 minutes).

Benign adrenal adenomas tend to be small (<4 cm), often have an intracytoplasmic fat content and appear less dense on noncontrast CT scan (<10 Hounsfield units), and exhibit rapid contrast washout during delayed contrast imaging (>50% at 10 minutes). T

Question 81

Endocrine

Answer 81

Hypomagnesemia causes functional, reversible parathyroid hypofunction and must be excluded before a low or inappropriately normal parathyroid level is attributed to hypoparathyroidism.

ionized calcium should only be checked when the patient’s albumin is low

Question 82

Endocrine

Answer 82

First-line therapy for toxic adenoma is radioactive iodine (131I) therapy or surgery.

Question 83

Endocrine

Answer 83

Patients with primary hyperparathyroidism who do not undergo surgery require monitoring of serum calcium and creatinine every 6 to 12 months and bone mineral density of the lumbar spine, hip, and distal radius every 2 years.

indications for parathyroidectomy include increase in serum calcium level ≥1 mg/dL (0.25 mmol/L) above upper limit of normal; creatinine clearance <60 mL/min, 24-hour urine calcium >400 mg/day (>10 mmol/day), or increased stone risk by biochemical stone risk analysis; presence of nephrolithiasis or

Cinacalcet is indicated to treat symptomatic, severe hypercalcemia in adults with primary hyperparathyroidism for whom parathyroidectomy cannot be performed

Question 84

Endocrine

Answer 84

Subclinical hypothyroidism is characterized by a serum thyroid-stimulating hormone (TSH) level above the upper limit of the reference range and normal free thyroxine (T4) level; before making this diagnosis, however, transient elevation of serum TSH should be ruled out by repeating the measurement of TSH in 2 to 3 months.

Thyrotropin receptor antibodies would be more consistent with Graves disease

Question 85

Endocrine

Answer 85

Ultrasound can confirm the presence of thyroid nodules palpated on examination and based on findings can help to determine if fine-needle aspiration is needed to assess for malignancy.

Ultrasound can confirm the presence of thyroid nodules palpated on examination and those detected on other imaging studies. Ultrasound must be performed prior to fine-needle aspiration biopsy (FNAB) to confirm the presence of a nodule, determine that biopsy is indicated,

Question 86

Endocrine

Answer 86

Serum thyroid-stimulating hormone level cannot be used to monitor and assess for adequacy of thyroid hormone replacement dosing in secondary hypothyroidism; the levothyroxine dose is adjusted based on free thyroxine (T4) levels with the goal of obtaining a value within the upper half of the normal reference range.

Question 87

Endocrine

Answer 87

Treatment for hypoglycemic unawareness is to reduce the insulin dose and avoid hypoglycemia in order to provide the body an opportunity to restore the ability to detect hypoglycemia.

Question 88

Endocrine

Answer 88

Antithyroid (Methimazole) drug-related agranulocytosis affects between one in 300 and one in 500 patients taking therapy and may present with fever and sore throat; initial management includes stopping the drug and assessment of the neutrophil count.

granulocytosis from methimazole usually occurs within the first several months of initiating therapy but generally is not seen with doses below 20 mg per day

Question 89

Endocrine

Answer 89

An increased risk of diabetic ketoacidosis with mild to moderate glucose elevations has been associated with the use of all the approved sodium-glucose transporter-2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin).

Glipizide is a sulfonylurea. Sulfonylurea agents work by stimulating insulin secretion. Sulfonylurea agents are associated with weight gain, and they can cause hypoglycemia. T

Question 90

Endocrine

Answer 90

Secondary hypogonadism is characterized by low testosterone level and low or inappropriately normal serum luteinizing hormone and follicle-stimulating hormone concentrations; MRI of the pituitary is typically performed to evaluate secondary hypogonadism in the absence of obvious reversible causes such as drugs.

Question 91

Endocrine

Answer 91

In patients with myxedema coma, intravenous hydrocortisone should be administered before thyroid hormones to treat possible adrenal insufficiency.

Following the administration of glucocorticoids, intravenous thyroid hormone replacement should be initiated. Treatment with levothyroxine is universally recommended

Question 92

Endocrine

Answer 92

Iron-deficiency anemia can erroneously increase the hemoglobin A1c level due to an increase in the proportion of older erythrocytes.

Question 93

Endocrine

Answer 93

Lobectomy is the treatment of choice for low-risk papillary thyroid cancer that is confined to the thyroid gland, completely resected at surgery, does not demonstrate aggressive pathologic features (lymphovascular invasion or tall cell variant), and has not metastasized.

Question 94

Endocrine

Answer 94

A low urine osmolality in the setting of a high serum osmolality and high serum sodium in a patient with polyuria is diagnostic of diabetes insipidus.

Question 95

Endocrine

Answer 95

Thyroid storm is a severe manifestation of thyrotoxicosis with life-threatening secondary systemic decompensation; it occurs most commonly with underlying Graves disease coupled with a precipitating factor such as surgery.

patients with adrenal crisis usually present with hypotension, hyponatremia, and hyperkalemia, in addition to gastrointestinal manifestations.

Question 96

Endocrine

Answer 96

In patients with diabetic ketoacidosis, intravenous insulin therapy should be continued until complete resolution of the anion gap acidosis; as acidosis improves, it may be necessary to reduce the insulin infusion rate and add intravenous dextrose to prevent hypoglycemia.

Question 97

Endocrine

Answer 97

In patients with diabetic ketoacidosis, intravenous insulin therapy should be continued until complete resolution of the anion gap acidosis; as acidosis improves, it may be necessary to reduce the insulin infusion rate and add intravenous dextrose to prevent hypoglycemia.

Question 98

Endocrine

Answer 98

Type 2 amiodarone-induced thyrotoxicosis (destructive thyroiditis) can be treated with moderate- to high-dose prednisone that can be gradually tapered over 1 to 3 months.

Methimazole is most effective in treating type 1 (hyperthyroidism) amiodarone-induced thyrotoxicosis, which occurs in patients with Graves disease or thyroid nodules.

Question 99

Endocrine

Answer 99

An androgen-secreting ovarian tumor should be considered in patients with abrupt, rapidly progressive, or severe hyperandrogenism as well as in women with marked hyperandrogenemia (total testosterone >150 ng/dL [5.2 nmol/L]).

Question 100

endocrine

Answer 100

Osteomalacia related to malabsorption or dietary factors is characterized by low 25-hydroxyvitamin D, calcium, and phosphate levels and elevated parathyroid hormone and alkaline phosphatase levels.

Question 101

An adrenal incidentaloma is a mass >1 cm that is discovered incidentally. What are the two things to determine immediately about an An adrenal incidentaloma?

Answer 101

The two goals of evaluation are to determine if an adenoma is functioning and if it is
malignant.

Question 102

what are 4 three indications to resect an incidental adrenal mass?

Answer 102

indications for Adrenalectomy
* Suspicious imaging
- Growth >20% plus 5 mm increase in diameter on repeat imaging
- greater than 4 cm
- Unilateral adrenal tumor with clinically significant hormone excess

Question 103

In pts with an incidental adrenal mass, testing for hormone excess should be performed. what 2 tests should be done in all of these pts?

Answer 103

1. low-dose (1-mg) dexamethasone suppression test
2. Catecholamines: test for urine or plasma metanephrines or urine catecholemines

Question 104

when is Surgery recommended for adrenal masses ?

Answer 104

Surgery is recommended for adrenal masses >4 cm in diameter or functioning tumors.

Question 105

what is the preferred treatment for achieving inpatient glycemic control?

Answer 105

Insulin is the preferred treatment for achieving inpatient glycemic control.

Question 106

How are Critically ill patients with type 2 diabetes are treated when plasma glucose
levels exceed 180 to 200 mg/dL.?

Answer 106

Critically ill patients with type 2 diabetes are treated with IV insulin infusion when plasma glucose levels exceed 180 to 200 mg/dL. Glucose goals are 140 to 180 mg/dL.

Question 107

For non–critically ill patients with T2DM, who are eating, how should BG greater than 180 be treated?

Answer 107

For non–critically ill patients who are eating, the insulin regimen should incorporate
both basal and prandial coverage. Prandial coverage can be supplemented with
correction factor insulin for preprandial hyperglycemia.

Question 108

Can you use sliding scale insulin ALONE to treat in-hospital hyperglycemia?

Answer 108

Do not select sliding scale insulin alone to treat in-hospital hyperglycemia.

Question 109

when T2DM pts are hospitalized, should you continue outpatient oral or noninsulin injectable agents?

Answer 109

Continuing outpatient oral or noninsulin injectable agents is not recommended when
patients are hospitalized because of the potential for hemodynamic or nutritional
changes.

Question 110

which clinical syndrome is associated with polyuria; nocturia; and an inability to concentrate urine because of insufficient arginine
vasopressin release?

Answer 110

insufficient arginine
vasopressin (AVP, ADH) release (central DI)

Question 111

which clinical syndrome is associated with polyuria; nocturia; and an inability to concentrate urine because of insufficient activity AVP?

Answer 111

nephrogenic DI

Question 112

In Diabetes Insipidus, what is the urine osm, serum osm and Na? (low/high?

Answer 112

An inappropriately low urine osmolality in the setting of an elevated serum osmolality
and hypernatremia in a patient with polyuria is diagnostic OF Diabetes Insipidus.

Question 113

what is the treatment for central DI?

Answer 113

Central DI is treated with desmopressin.

Question 114

When a dx of DI is uncertain, what test can be done?

Answer 114

A water deprivation test can be performed when the diagnosis is uncertain. Following
water deprivation, an elevated serum osmolality or hypernatremia with inappropriately
dilute urine is diagnostic.

Question 115

For DI, what serum Na and serum Osm are dx? (Low/high)

Answer 115

Following water deprivation, an elevated serum osmolality or hypernatremia with inappropriately
dilute urine is diagnostic.

Question 116

what is one way to evaluate the response to help differentiate central from
nephrogenic DI?

Answer 116

Evaluating the response to desmopressin can help differentiate central from
nephrogenic DI. If the desmopressin challenge test is positive (urine concentrates, indicating central DI), order an MRI of the pituitary gland. If the test is negative (urine does not concentrate,
indicating nephrogenic DI), order kidney ultrasonography.

Question 117

what tests are used to dx type 1 diabetes?>

Answer 117

Measuring
antibodies to GAD65 and IA-2 is recommended for initial confirmation.

Question 118

what Insulin Dose adjustment in Diabetes Mellitus should be made when Prelunch hypoglycemia?

Answer 118

Too much rapid-acting insulin at breakfast or too much morning NPH insulin

Question 119

what Insulin Dose adjustment in Diabetes Mellitus should be made when Fasting or nocturnal hypoglycemia?

Answer 119

Too much basal insulin

Question 120

what Insulin Dose adjustment in Diabetes Mellitus should be made when Bedtime hyperglycemia?

Answer 120

Not enough rapid-acting insulin at dinner

Question 121

what Insulin Dose adjustment in Diabetes Mellitus should be made when Predinner hyperglycemia?

Answer 121

Not enough rapid-acting insulin at lunch or not enough morning NPH insulin

Question 122

what Insulin Dose adjustment in Diabetes Mellitus should be made when Prelunch hyperglycemia?

Answer 122

Not enough rapid-acting insulin at breakfast or not enough morning NPH insulin

Question 123

what Insulin Dose adjustment in Diabetes Mellitus should be made when Fasting hyperglycemia?

Answer 123

Not enough basal insulin

Question 124

what Insulin Dose adjustment in Diabetes Mellitus should be made when Predinner or bedtime hypoglycemia?

Answer 124

Too much rapid-acting insulin at lunch or dinner or too much morning NPH

Question 125

Hypoglycemia unawareness describes the presence of severely low plasma glucose
levels that occur without warning symptoms followed by sudden loss or impairment of
consciousness. how can this be treated?

Answer 125

Lowering the insulin dose and allowing the average plasma
glucose level to increase for several weeks may restore sensitivity to hypoglycemia.

Question 126

Who should be screened for T2DM?

Answer 126

The USPSTF recommends screening for abnormal blood glucose as part of
cardiovascular risk assessment in adults aged 35 to 70 years who are overweight or
obese.
The ADA recommends screening overweight adults (BMI ≥25; ≥23 in Asian Americans)
with at least one additional risk factor and all patients >45 years.

Question 127

CAN T2DM BE DX WITH TWO DIFFERENT TYPES OF TESTS AT ONCE?

Answer 127

If two separate tests are done simultaneously and
both are abnormal, diagnose diabetes. If only one of the two tests is abnormal, repeat
the abnormal test.

Question 128

What level glucose is dx of T2DM?

Answer 128

A random plasma glucose level ≥200 mg/dL with hyperglycemic symptoms is
diagnostic of diabetes and does not warrant repeat measurement.

Question 129

IN what 3 scenarios will a1c be falsely low?

Answer 129

Hemoglobin A1c will be falsely low in patients with hemolytic anemia, patients
taking erythropoietin, or patients with kidney injury.

Question 130

what is the recommended first-line oral agent for newly diagnosed type 2
diabetes.?

Answer 130

Metformin is the recommended first-line oral agent for newly diagnosed type 2
diabetes.

Question 131

For T2DM, for patients who are not at goal with metformin, what is the next agent in line for patients with ASCVD or CKD?

Answer 131

If not at goal, next preferred therapy is an SGLT2 inhibitor or a glucagon-like
peptide 1 (GLP-1) receptor agonist for patients at risk for or with established ASCVD or with established kidney disease, and an SGLT2 inhibitor for HF.

Question 132

In most patients who need the greater glucose-lowering effect of an injectable
medication, what is the preferred option? .

Answer 132

In most patients who need the greater glucose-lowering effect of an injectable
medication, GLP-1 receptor agonists are preferred to insulin.

Question 133

Which two classes of T2DM meds are good for weight loss?

Answer 133

If weight loss is a desired effect, GLP-1 receptor agonists and SGLT2 inhibitors are
the best choices.

Question 134

Which two classes of T2DM meds are good for ASCVD?

Answer 134

GLP-1 receptor agonists and SGLT2 inhibitors

Question 135

Which two classes of T2DM meds are good for HF?

Answer 135

SGLT2 inhibitors

Question 136

Which clinical syndrome is associated with this pic?

Answer 136

Nonproliferative Diabetic Retinopathy, Dot-and-blot hemorrhages and clusters of hard, yellowish exudates are
characteristic of nonproliferative diabetic retinopathy.

Question 137

Which clinical syndrome is associated with this pic?

Answer 137

Proliferative Diabetic Retinopathy,
A network of new vessels (neovascularization) is shown protruding from the optic
nerve.

Question 138

Which clinical syndrome is associated with the normal pituitary gland is not visualized or is
excessively small on MRI?

Answer 138

Empty Sella Syndrome

Question 139

what initial workup should be done for patients with empty sella syndrome who are asymptomatic?

Answer 139

In asymptomatic persons, obtain cortisol, TSH, and free (or total) T4 measurements.

Question 140

In patients without an obvious cause of Gynecomastia, what tests should be obtained?

Answer 140

In patients without an obvious cause, obtain hCG and 8 AM fasting testosterone and
estradiol levels.

Question 141

What is the most common cause of hypercalcemia in outpatients?

Answer 141

Primary hyperparathyroidism is the most common cause of hypercalcemia in
outpatients.

Question 142

what 3 medications are known to cause Hypercalcemia ?

Answer 142

Hypercalcemia may also occur with the use of lithium (PTH mediated) or thiazide
diuretics (non-PTH mediated) and in the setting of excessive ingestion of vitamin D and
calcium.

Question 143

What is the most common cause of hypercalcemia in hospitalized patients.?

Answer 143

Malignancy is the most common cause of hypercalcemia in hospitalized patients.

Question 144

what other pulm clinical syndrome is associated with with hypercalcemia (10% of patients) and hypercalciuria
(50% of patients)?

Answer 144

Sarcoidosis may be associated with hypercalcemia (10% of patients) and hypercalciuria
(50% of patients).

Question 145

Which clinical syndrome is associated with hypercalcemia and PTH elevated and phosphorus low?

Answer 145

Primary hyperparathyroidism

Question 146

Which clinical syndrome is associated with hypercalcemia and PTH suppressed; phosphorus normal or low, PTH-related protein may be elevated?

Answer 146

Humoral hypercalcemia of malignancy

Question 147

Which clinical syndrome is associated with hypercalcemia and PTH suppressed; phosphorus normal or low, Lytic bone metastases result in increased mobilization of calcium from the bone?

Answer 147

Local osteolytic lesions

Question 148

Which clinical syndrome is associated with hypercalcemia and PTH suppressed; phosphorus elevated with new kidney injury and anemia?

Answer 148

Multiple myeloma

Question 149

Which clinical syndrome is associated with hypercalcemia and PTH suppressed; phosphorus elevated; calcitriol elevated?

Answer 149

Granulomatous disease (sarcoidosis and
TB) and B-cell lymphoma

Question 150

Which clinical syndrome is associated with hypercalcemia and PTH suppressed; phosphorus, creatinine, carbon dioxide elevated?

Answer 150

Milk-alkali syndrome

Question 151

In patients with hypercalcemia and normal PTH levels, what should be measured next and why?

Answer 151

In patients with hypercalcemia and normal PTH levels, measure urinary calcium
excretion to exclude familial hypocalciuric hypercalcemia.

Question 152

how is Multiple myeloma dx?

Answer 152

Diagnose with serum and urine protein immunoelectrophoresis

Question 153

what is the most common manifestation of MEN1.?

Answer 153

Primary hyperparathyroidism is the most common manifestation of MEN1.

Question 154

what is the treatment for severe, symptomatic hypercalcemia?

Answer 154

For severe, symptomatic hypercalcemia, select:
* volume resuscitation with 0.9% saline
* IV bisphosphonates
* oral glucocorticoid therapy (if caused by multiple myeloma, B-cell lymphoma, or
sarcoidosis)

Question 155

what is the tx for patients with primary hyperparathyroidism and
hypercalcemic complications, such as kidney stones, bone disease?

Answer 155

Parathyroidectomy is indicated for patients with primary hyperparathyroidism and
hypercalcemic complications, such as kidney stones, bone disease, or previous episodes
of hypercalcemic crisis.

Question 156

Which clinical syndrome is associated with a precipitous fall in the serum calcium level caused by relative
hypoparathyroidism after parathyroidectomy ?

Answer 156

hungry bone” syndrome

Question 157

when are Loop diuretics recommended in the treatment of hypercalcemia?

Answer 157

Loop diuretics are not recommended in the treatment of hypercalcemia unless
kidney failure or HF is present, in which case, volume expansion should precede
the administration of loop diuretics to avoid hypotension and further kidney
injury.

Question 158

what is The most common cause of Cushing syndrome ?

Answer 158

The most common cause of Cushing syndrome is the use of systemic, topical, intra-
articular, or inhaled glucocorticoids.

Question 159

what is the difference in ACTH levels between ACTH-dependent causes of Cushing syndrome and
ACTH-independent causes?

Answer 159

1. ACTH-dependent causes of Cushing syndrome are defined by ACTH levels elevated or
   inappropriately “normal” in relation to the cortisol level:
2. ACTH-independent causes of Cushing syndrome are defined by low or “normal” ACTH
   levels in relation to the cortisol level

Question 160

Which clinical syndrome is associated with proximal muscle weakness, facial plethora, supraclavicular or dorsocervical (“buffalo hump”) fat pads, wide (>1 cm) violaceous striae?

Answer 160

Cushing syndrome

Question 161

what are the 2 ACTH-independent causes of Cushing syndrome?

Answer 161

adrenal adenomas
* adrenal carcinomas

Question 162

what are the 2 ACTH-dependent causes of Cushing syndrome?

Answer 162

• ACTH-secreting pituitary adenomas (Cushing disease)
• ACTH-secreting carcinomas and carcinoid tumors

Question 163

what is the First-line diagnostic study for suspected Cushing disease?

Answer 163

• 1-mg overnight dexamethasone suppression test (failure to suppress serum cortisol to <3 μg/dL)
• 24-hour urine cortisol level (elevated)
• late night salivary cortisol level (elevated)

Question 164

In the evaluation of cushing, If the cortisol level is elevated (or not suppressible), what should be ordered next?

Answer 164

If the cortisol level is elevated (or not suppressible), obtain an ACTH level to
differentiate ACTH-dependent from ACTH-independent hypercortisolism.

Question 165

In the Evaluation of Hypercortisolism, when you see a Morning ACTH elevated, what should be done next?

Answer 165

Pituitary MRI or CT

Question 166

In the Evaluation of Hypercortisolism, when you see a Morning ACTH suppressed or normal?

Answer 166

Adrenal CT

Question 167

In Cushing syndrome, what are 3 reasons for a False-positive results (failure to suppress cortisol) ?

Answer 167

False-positive results (failure to suppress cortisol) with the 1-mg dexamethasone
suppression test are common owing to alcohol use, obesity, and psychological
disorders.

Question 168

What is the definitive treatment for benign and malignant cortisol-secreting adrenal tumors?

Answer 168

Surgical resection is the definitive treatment for benign and malignant cortisol-
secreting adrenal tumors.

Question 169

Which clinical syndrome is associated with with extreme hyperglycemia (>600 mg/dL) in older patients with type 2 diabetes mellitus, no or low serum levels of ketones, and a relatively normal arterial pH and bicarbonate level.?

Answer 169

Hyperglycemic hyperosmolar syndrome

Question 170

In treating DKA, when should you reduce the insulin infusion drip?

Answer 170

Reducing the insulin infusion before complete clearing of ketones will cause a
relapse of DKA.

Question 171

when treating DKA, when do you switch to 5% dextrose with 0.45% saline at 150-250
mL/h to avoid hypoglycemia?

Answer 171

When plasma glucose level
reaches 200 mg/dL in patients
with DKA or 300 mg/dL in HHS
in the setting of continued IV
insulin, switch to 5% dextrose
with 0.45% saline at 150-250
mL/h to avoid hypoglycemia.

Question 172

in tx DKA, below what K level should you not start insulin?

Answer 172

If serum potassium is <3.3 mEq/L, do not
start insulin;

Question 173

in tx DKA, when should you consider sodium
bicarbonate?

Answer 173

If pH is <6.9,
consider sodium
bicarbonate,

Question 174

what are the 2 most common causes of hyperthyroidism ?

Answer 174

The most common causes of hyperthyroidism are Graves disease and toxic adenoma(s).

Question 175

Which clinical syndrome is associated with goiter,
ophthalmopathy (proptosis, chemosis, and extraocular muscle palsy), and pretibial
myxedema?

Answer 175

Graves disease

Question 176

what initial labs are needed to make the diagnosis of thyrotoxicosis?

Answer 176

Order serum TSH and free T4 levels to make the diagnosis of thyrotoxicosis.

Question 177

in making the diagnosis of thyrotoxicosis, what is done next if TSH is suppressed but T4 is normal?

Answer 177

If TSH is suppressed but T4 is normal, order free T3 to diagnose T3 toxicosis (rare).

Question 178

in patients with thyrotoxicosis caused by surreptitious use of thyroid hormone, which lab level cab be measured and will be low?.

Answer 178

Intake of exogenous thyroid hormone suppresses thyroglobulin levels, which makes its
measurement useful (when low) in patients with thyrotoxicosis caused by surreptitious
use of thyroid hormone.

Question 179

Which lab in elevated uniquely n thyroiditis, compared two which two are elevated in Graves?

Answer 179

An elevated serum ESR supports thyroiditis, whereas TSH-receptor antibodies and
thyroid-stimulating immunoglobulins are associated with Graves disease.

Question 180

In Interpreting Thyroid Function Tests in Hyperthyroidism, which clinical syndrome is associated with ↓ TSH, ↑ free T4?

Answer 180

Primary hyperthyroidism

Question 181

In Interpreting Thyroid Function Tests in Hyperthyroidism, which clinical syndrome is associated with ↓ TSH, ↑ T3, normal free T4?

Answer 181

Primary hyperthyroidism with T3 toxicosis

Question 182

In Interpreting Thyroid Function Tests in Hyperthyroidism, which clinical syndrome is associated with ↓ TSH, normal T3 and free T4, without symptoms?

Answer 182

Subclinical hyperthyroidism

Question 183

In Interpreting Thyroid Function Tests in Hyperthyroidism, which clinical syndrome is associated with ↑ TSH, ↑ T3, ↑ free T4?

Answer 183

Secondary hyperthyroidism from a pituitary tumor (central hyperthyroidism, very rare)

Question 184

which Radioactive Iodine Uptake and Scan Interpretation is associated with Diffuse homogeneous increased uptake?

Answer 184

Graves disease

Question 185

which Radioactive Iodine Uptake and Scan Interpretation is associated with Patchy areas of increased uptake?

Answer 185

Toxic multinodular goiter

Question 186

which Radioactive Iodine Uptake and Scan Interpretation is associated with Focal increased uptake with decreased uptake in the rest of the
gland?

Answer 186

Solitary adenoma

Question 187

which Radioactive Iodine Uptake and Scan Interpretation is associated with Decreased or no uptake?

Answer 187

Iodine load (IV contrast or amiodarone)

Thyroiditis (silent, subacute, postpartum, or amiodarone
induced)
Surreptitious ingestion of excessive thyroid hormone

Question 188

For patients with thyrotoxicosis, what treatment can be used to reduce adrenergic
symptoms rapidly?

Answer 188

Most patients with thyrotoxicosis benefit from β-blockers to reduce adrenergic
symptoms rapidly.

Question 189

what 2 populations should Radioactive iodine ibe avoided?

Answer 189

Radioactive iodine is not used during pregnancy or breastfeeding and may aggravate
Graves ophthalmopathy.

Question 190

What is the tx for Moderate to severe Graves ophthalmopathy ?

Answer 190

Moderate to severe Graves ophthalmopathy may require treatment with
glucocorticoids, surgery, or teprotumumab.

Question 191

what is the First-line antithyroid medication for most patients with thyrotoxicosis?

Answer 191

Methimazole

Question 191

what is the First-line antithyroid medication for most patients with thyrotoxicosis?

Answer 191

Methimazole

Question 192

what main size effect should you watch for with Methimazole?

Answer 192

Agranulocytosis

Question 193

in treating thyrotoxicosis, what is the tx in 1st trimester preggo women?

Answer 193

Propylthiouracil

Question 194

besides pregnancy, when is PTU preferred to be used in thyrotoxicosis?

Answer 194

PTU is preferred in thyroid storm (inhibits peripheral T4-T3 conversion)

Question 195

which clinical syndrome is associated with by TSH suppression with normal T4 and T3
levels.?

Answer 195

Subclinical hyperthyroidism

Question 196

in evaluation of subclinical hyperthyroidism, at what TSH level is treatment recommended aside from symptoms?

Answer 196

Treatment is recommended for TSH <0.1 μU/L and patients with symptoms.

Question 197

In the Management of Thyrotoxicosis, if you see Sympathetic
nervous system
symptoms, what should you use to treat?

Answer 197

Atenolol or propranolol

Question 198

In the Management of Thyrotoxicosis, if you see Severe Graves
ophthalmopathy, what should you use to treat?

Answer 198

Methimazole or thyroidectomy
Avoid radioactive iodine

Question 199

In the Management of Thyrotoxicosis, if you see Pregnancy, what should you tx with?

Answer 199

Propylthiouracil in first trimester of pregnancy; methimazole thereafter. Radioactive iodine is contraindicated

Question 200

In the Management of Thyrotoxicosis, if you see Subclinical
hyperthyroidism with TSH <0.1 μU/mL, what should you think?

Answer 200

Methimazole if TSH <0.1 μU/mL

Question 201

In the Management of Thyrotoxicosis, if you see Subacute thyroiditis, how should you treat?

Answer 201

NSAIDs or glucocorticoids for pain management, atenolol or propranolol for symptoms of hyperthyroidism,
levothyroxine for symptomatic hypothyroidism, and periodic thyroid studies.

Question 202

In the Management of Thyrotoxicosis in a pt with Thyroid storm, how should you tx?

Answer 202

Propylthiouracil (preferred) or methimazole, iodine-potassium solutions, glucocorticoids, and β-blockers

Question 203

Which clinical syndrome is associated with fever or sore throat in a patient taking methimazole or propylthiouracil ?

Answer 203

A fever or sore throat in a patient taking methimazole or propylthiouracil should
be presumed to be agranulocytosis until proven otherwise.

Question 204

what is the most common cause of primary insufficiency.?

Answer 204

Autoimmune adrenalitis is the most common cause of primary insufficiency.

Question 205

what is the most common cause of secondary insufficiency
(hypothalamic-pituitary suppression)?

Answer 205

Glucocorticoid use is the most common cause of secondary insufficiency
(hypothalamic-pituitary suppression).

Question 206

Which serum cortisol level confirms cortisol deficiency and which level exclude the diagnosis?

Answer 206

An 8:00 AM serum cortisol <3 μg/dL confirms cortisol deficiency and values >18 μg/dL
exclude the diagnosis.

Question 207

For patients with unequivocally low cortisol levels, what test can be done next to help
distinguish between primary and secondary adrenal insufficiency?

Answer 207

For patients with unequivocally low cortisol levels, a morning ACTH level can help
distinguish between primary and secondary adrenal insufficiency.

Question 208

In the Evaluation of Hypocortisolism, if you see a Morning ACTH elevated, what should be done next?

Answer 208

Adrenal CT

Question 209

In the Evaluation of Hypocortisolism, if you see a Morning ACTH suppressed or “normal” what should be done next??

Answer 209

Pituitary MRI

Question 210

For nondiagnostic cortisol values (as opposed to low unequivical) , what additional test can be done to help dx adrenal insufficiency.?

Answer 210

For nondiagnostic cortisol values, select stimulation testing with synthetic ACTH
(cosyntropin). A stimulated serum cortisol >18 μg/dL excludes adrenal insufficiency.

Question 211

If acute adrenal insufficiency is suspected, what is the tx?

Answer 211

If acute adrenal insufficiency is suspected, treat empirically with high-dose (4 mg)
dexamethasone and IV saline without waiting for the ACTH and cortisol level results to
return from the laboratory.

Question 212

Does Dexamethasone interfere with the serum cortisol
assay.?

Answer 212

Dexamethasone does not interfere with the serum cortisol
assay.

Question 213

what is the stress dose for steroids in pts with adrenal insufficiency?

Answer 213

IV hydrocortisone 100 mg followed by 50 mg every 6 h for major stress (major
surgery, trauma, critical illness, childbirth)

Question 214

is fludrocortisone in primary adrenal insufficiency ?

Answer 214

fludrocortisone is not required in primary adrenal insufficiency if the
hydrocortisone dose >40 mg/d

Question 215

which lab abnormalities are seen in (primary adrenal insufficiency only)?

Answer 215

hyponatremia and hyperkalemia (primary adrenal insufficiency only)

Question 216

what is the cause of Most cases of hypocalcemia?

Answer 216

Most cases of hypocalcemia are caused by low serum albumin levels; the ionized
calcium concentration is normal.

Question 217

What is the relationship with albumin and calcium?

Answer 217

Total calcium declines by 0.8 mg/dL for each 1 g/dL
decrement in serum albumin concentration.

Question 218

what is a A positive Trousseau’s sign and what lab abn is related?

Answer 218

A positive Trousseau’s sign is characterized by the appearance of a carpopedal spasm which involves flexion of the wrist, thumb, and MCP joints along with hyperextension of the IP joints. This spasm results from the ischemia that is induced by compression through the inflated cuff.

Question 219

what should be ordered to evaluate hypoparathyroidism?

Answer 219

Order calcium, phosphate, magnesium, creatinine, PTH, 25-hydroxyvitamin D, albumin,

and/or ionized calcium tests. Order an ECG to evaluate for QT interval prolongation.

Question 220

In evaluating Hypocalcemia, Which clinical syndrome is associated with hypocalcemia and Recent parathyroidectomy ?

Answer 220

“Hungry bone” syndrome

Question 221

In evaluating Hypocalcemia, Which clinical syndrome is associated with hypocalcemia and Magnesium deficiency (small bowel bypass, diarrhea, alcoholism, diuretic therapy)?

Answer 221

Impaired PTH secretion and PTH
resistance

Question 222

In evaluating Hypocalcemia, Which clinical syndrome is associated with Hypophosphatemia; bone tenderness or fibromyalgia-like syndrome, weakness, gait difficulty, osteomalacia?

Answer 222

Vitamin D deficiency

Question 223

In evaluating Hypocalcemia, Which clinical syndrome is associated with Hyperphosphatemia; elevated PTH and low 1,25-dihydroxyvitamin D levels?

Answer 223

CKD

Question 224

In evaluating Hypocalcemia, Which clinical syndrome is associated with Hyperphosphatemia; low PTH and variable vitamin D levels?

Answer 224

Hypoparathyroidism

Question 225

What is the tx for acute symptomatic hypocalcemia?

Answer 225

Treat acute symptomatic hypocalcemia with IV calcium gluconate and vitamin D.

Question 226

How is Chronic hypocalcemia treated ?

Answer 226

Chronic hypocalcemia is treated with oral calcium supplements and vitamin D.

Question 227

Which clinical syndrome is associated with hypoglycemia typically occurs within 5 hours of the last meal and is commonly caused by previous gastrectomy or gastric bypass surgery.?

Answer 227

Postprandial hypoglycemia

Question 228

In the Diagnosis of Nondiabetic Fasting Hypoglycemia, what should you consider if you see Serum C-peptide levels are inappropriately elevated at time of hypoglycemia? How do you dx?

Answer 228

Suspect Surreptitious use of oral
hypoglycemic agents. Perform urine screen for sulfonylurea and meglitinide metabolites.

Question 229

In the Diagnosis of Nondiabetic Fasting Hypoglycemia, what should you consider if you see Serum C-peptide levels are low at time of hypoglycemia?

Answer 229

Surreptitious use of
insulin

Patient has access to insulin. Serum C-peptide levels are low at time of hypoglycemia.

Question 230

In the Diagnosis of Nondiabetic Fasting Hypoglycemia, when should you suspect an Insulinoma? what does the insulin, c peptide and glucose levels do?

Answer 230

Perform 72-hour fast and document fasting plasma glucose level <45 mg/dL, serum insulin >5-6 mU/L,

and elevated C-peptide levels. If positive, schedule abdominal CT.

Question 231

for patients with fasting hypoglycemia what is the first step in evaluation?

Answer 231

Begin the evaluation of all patients with fasting hypoglycemia with screening for
surreptitious use of an oral hypoglycemia agent, such as a sulfonylurea or insulin.

Question 232

Which endocrine syndrome is associated with?

Answer 232

MEN1 can present as hyperparathyroidism, pituitary neoplasms, or pancreatic NETs.
Pancreatic NETs include gastrinomas that can cause PUD and insulinomas that can
cause hypoglycemia.

Question 233

can you use home glucometers to document hypoglycemia?

Answer 233

Do not use home glucometers to document hypoglycemia, because they may be
inaccurate.

Question 234

In Asymptomatic hypoglycemia with a plasma glucose level <60 mg/dL in patients without underlying disease, does this require workup?

Answer 234

Asymptomatic hypoglycemia with a plasma glucose level <60 mg/dL is often
found after fasting in patients without underlying disease and does not require
evaluation.

Question 235

How do you Treat acute hypoglycemia ?

Answer 235

Treat acute hypoglycemia with oral carbohydrates, IV glucose, or glucagon.

Question 236

What is the optima management of postprandial hypoglycemia associated with previous gastrectomy or gastric bypass surgery?

Answer 236

For management of postprandial hypoglycemia associated with previous gastrectomy or gastric bypass surgery, choose small mixed meals containing protein, fat, and high-
fiber complex carbohydrates.

Question 237

Are Serum C-peptide levels associated with endogenous insulin or exogenous insulin?

Answer 237

Serum C-peptide levels are from endogenous insulin. If someone is ingesting insulin, c pep should be normal

Question 238

which clinical syndrome is associated with a patient who has had pituitary disease or from previous surgery or radiation therapy to the sella and now have a TSH and free T4 are suppresse?.

Answer 238

Central hypothyroidism results from pituitary disease or from previous surgery or
radiation therapy to the sella. TSH and free T4 are suppressed.

Question 239

what condition should be suspected in patients with TSH and free T4 are suppressed?

Answer 239

Central hypothyroidism

Question 240

which 4 drugs are associated with Medication-induced hypothyroidism?

Answer 240

Medication-induced hypothyroidism can occur with the use of certain drugs,
including lithium carbonate, interferon alfa, interleukin-2, and amiodarone.

Question 241

what tests should you order to make the diagnosis of Hypothyroidism?

Answer 241

Order TSH and free T4 to make the diagnosis. Measurement of T3 levels is generally not
necessary.

Question 242

what are The 4 most common causes of hypothyroidism?

Answer 242

The most common causes of hypothyroidism include:
* chronic lymphocytic (Hashimoto) thyroiditis
* thyroidectomy
* previous radioactive iodine ablation
* history of external beam radiation to the neck

Question 243

which lab is associated with Hashimoto
thyroiditis and helps make the dx ?

Answer 243

An antithyroid peroxidase antibody assay is associated with Hashimoto
thyroiditis but is not needed to make the diagnosis; high levels are associated with an
increased risk of permanent hypothyroidism.

Question 244

which illness syndrome occurs in patients who are acutely ill, have a low or normal free T4 and suppressed TSH (initially),
followed by elevated TSH (recovery phase)?

Answer 244

Nonthyroidal illness syndrome occurs in patients who are acutely ill with a
nonthyroidal illness. Testing reveals low or normal free T4 and suppressed TSH (initially),
followed by elevated TSH (recovery phase). Normalization of thyroid function tests
occurs 4 to 8 weeks after recovery.

Question 245

How long does it take for Normalization of thyroid function tests after an acute illness?

Answer 245

Normalization of thyroid function tests
occurs 4 to 8 weeks after recovery.

Question 246

Are Thyroid scan and radioactive iodine uptake tests used to make the
diagnosis of hypothyroidism.?

Answer 246

Thyroid scan and radioactive iodine uptake tests are not used to make the
diagnosis of hypothyroidism.

Question 247

which clinical syndrome is associated with ↑ TSH, ↓ free T4?

Answer 247

Primary hypothyroidism

Question 248

which clinical syndrome is associated with ↑ TSH, normal T4?

Answer 248

Subclinical hypothyroidism

Question 249

which clinical syndrome is associated with ↓ TSH, ↓ free T4 ?

Answer 249

Secondary (central) hypothyroidism; consider hypopituitarism

Question 250

what is used to treat hypothyroidism?

Answer 250

Levothyroxine is used to treat hypothyroidism.

Question 251

What 4 indications are there to treat subclinical
hypothyroidism? at what TSH level?

Answer 251

Most guidelines support these treatment indications for subclinical
hypothyroidism (TSH >10 μU/mL):
* symptomatic
* pregnant or planning to become pregnant
* possibly age <30 years

Question 252

Which 3 meds can decrease levothyroxine absorption and should be
taken at least 4 hours apart from levothyroxine?

Answer 252

Recall that celiac disease, calcium and iron supplements, and PPIs
can decrease levothyroxine absorption; medications affecting absorption should be
taken at least 4 hours apart from levothyroxine.

Question 253

What lab should be checked frequently during pregnancy in women with a known diagnosis of hypothyroidism?

Answer 253

Check thyroid function tests frequently during pregnancy in women with a
known diagnosis of hypothyroidism taking thyroxine, because maternal thyroxine
demand increases by 30% to 50%.

Question 254

After Beginning levothyroxine, when should you increase the dose and how frequent?

Answer 254

Begin levothyroxine at 25-50 μg/d

Increase by 25 μg every 6 weeks until TSH level is 1.0-2.5 μU/mL

Question 255

For women less than 35, what is the inability to conceive after 1 year of intercourse?

Answer 255

Infertility is defined as the inability to conceive after 1 year of intercourse without
contraception in women <35 years and after 6 months in women ≥35 years.

Question 256

which clinical syndrome is associated with sperm or testosterone production is decreased?

Answer 256

Male hypogonadism is present when sperm or testosterone production is decreased. It
can be a primary (testicular) or secondary (typically hypothalamic-pituitary) condition.

Question 257

What test is used to dx Testosterone deficiency?

Answer 257

Testosterone deficiency is diagnosed with two 8:00 AM total testosterone levels below
the reference range.

Question 258

In diagnosing testosterone deficiency, if the testosterone measurement is equivocal, what should be measured next?

Answer 258

if the testosterone measurement is equivocal, measure free testosterone.

Question 259

In diagnosing testosterone deficiency, if the testosterone measurement is low, what should be diagnosed next?

Answer 259

If the testosterone level is low, measure LH, FSH, and prolactin levels.

Question 260

In diagnosing testosterone deficiency, If the testosterone level is low and subsequent Elevated LH and FSH values are found, what is indicated?

Answer 260

Elevated LH and FSH values indicate primary testicular failure.

Question 261

In diagnosing testosterone deficiency, If the testosterone level is low and subsequent Low or normal LH and FSH levels, what is indicated?

Answer 261

Low or normal LH and FSH levels indicate secondary hypogonadism.

Question 262

In diagnosing testosterone deficiency, if secondary hypogonadism is confirmed, what other things should be checked next?

Answer 262

If secondary hypogonadism is confirmed, in addition to measuring prolactin, check iron
studies to rule out hemochromatosis and obtain an MRI to evaluate for hypothalamic or
pituitary lesions.

Question 263

which clinical syndrome is associated with acne, muscular hypertrophy, testicular atrophy, and gynecomastia ?

Answer 263

Men who self-administer anabolic steroids can come to medical attention because of
infertility. Physical examination typically reveals acne, muscular hypertrophy, testicular
atrophy, and gynecomastia (if the patient is using testosterone).

Question 264

If a patient is having regular morning
erections, has no gynecomastia on examination, and has a normal genital examination, should you measure serum testosterone ?

Answer 264

Do not measure serum testosterone if a patient is having regular morning erections, has no gynecomastia on examination, and has a normal genital examination.

Question 265

Before initiation of testosterone
replacement and during therapy, what two labs should be routinely monitored ?

Answer 265

Before initiation of testosterone
replacement and during therapy, routinely monitor hematocrit and PSA to screen for
the development of erythrocytosis and prostate cancer, respectively.

Question 266

Which MEN syndrome is associated with Medullary thyroid cancer ?

Answer 266

MEN2

Question 267

which clinical syndrome is associated with Pheochromocytoma (hypertension,
palpitations)?

Answer 267

MEN2

Question 268

which Two syndromes are present in MEN 1 that are not in MEN 2?

Answer 268

Pituitary neoplasms and pancreatic NETS:

Pancreatic NETs associated with gastrinoma (diarrhea, ulcers), insulinoma (fasting
hypoglycemia), vasoactive intestinal polypeptide-secreting tumor (watery diarrhea,
hypokalemia), carcinoid syndrome (diarrhea, flushing, right heart valvular lesion)

Pituitary neoplasms associated with prolactinoma(amenorrhea, erectile dysfunction),
acromegaly (enlargement of hands, feet, tongue; frontal bossing), Cushing disease
(bruising, hypertension, central obesity, hirsutism)

Question 269

What measurement of serum level should be measured in all patients with hyperparathyroidism?

Answer 269

About 50% of patients with primary hyperparathyroidism have coexisting vitamin
D deficiency, and serum and urine calcium levels may be decreased. Select
measurement of serum vitamin D levels in all patients with hyperparathyroidism.

Question 270

Which clinical syndrome is associated with failure of the organic matrix of bone to mineralize because of lack of available calcium or phosphorus?

Answer 270

Osteomalacia results from failure of the organic matrix of bone to mineralize because of
lack of available calcium or phosphorus.

Question 271

what patients with suspected osteomalacia, what conditions should you check for that may pre-dispose?

Answer 271

Evaluate for underlying conditions that may lead to intestinal malabsorption of vitamin
D, such as celiac disease, or abnormalities in vitamin D metabolism, such as liver and
kidney disease.

Question 272

How is a Diagnosis of osteomalacia made?

Answer 272

Diagnosis is confirmed with bone biopsy when necessary.

Question 273

when should women be screened for osteoporosis?

Answer 273

The USPSTF recommends screening bone mineral density with DEXA in women ≥65
years and in postmenopausal women <65 years who are at increased risk as
determined by a formal clinical risk assessment tool (e.g., FRAX).

Question 274

should you repeat annual DEXA in women with normal DEXA results without risk
factors?.

Answer 274

Do not repeat annual DEXA in women with normal DEXA results without risk
factors. The optimal screening interval is unknown.

Question 275

What t score is diagnostic for osteopenia vs osteoporosis?

Answer 275

Osteoporosis is characterized by an increased predisposition to fractures.
* DEXA T-score of −1.0 to −2.4 defines osteopenia.
* DEXA T-score of ≤−2.5 defines osteoporosis.

Question 276

what is The most common cause of osteoporosis in women? in men?

Answer 276

The most common cause of osteoporosis in women is estrogen deficiency and in men
is testosterone deficiency.

Question 277

What are the first-line therapy Treatment options for osteoporosis ?

Answer 277

Treatment options for osteoporosis include alendronate or risedronate is first-line therapy

Question 278

In patients with CKD4, who need treatment for osteoporosis what treatment is preferred?

Answer 278

denosumab (monoclonal antibody that inhibits osteoclast activation) may be
preferred in patients with stage 4 CKD and in those intolerant of or incompletely
responding to bisphosphonates

Question 279

What treatments for Osteoporosis are contraindicated in patients with CKD or esophageal disease?

Answer 279

Oral bisphosphonates are contraindicated in patients with CKD or esophageal disease.
IV zoledronate (once yearly) is an alternative therapeutic option.

Question 280

what two clinical conditions are Oral bisphosphonates are contraindicated ?

Answer 280

Oral bisphosphonates are contraindicated in patients with CKD or esophageal disease.
IV zoledronate (once yearly) is an alternative therapeutic option.

Question 281

what is a focal disorder of bone remodeling that leads to greatly accelerated
rates of bone turnover, disruption of the normal architecture of bone, and sometimes
gross deformities of bone (enlargement of the skull, bowing of the femur or tibia)?

Answer 281

Paget disease is a focal disorder of bone remodeling that leads to greatly accelerated
rates of bone turnover, disruption of the normal architecture of bone, and sometimes
gross deformities of bone (enlargement of the skull, bowing of the femur or tibia).

Question 282

what lab elevation suggest pagets disease?

Answer 282

Most patients are asymptomatic, and the disease is suspected when an isolated elevation of
alkaline phosphatase is detected in the absence of liver disease.

Question 283

which clinical syndrome is associated with bone pain, fractures, cranial nerve compression syndromes, spinal stenosis, nerve root syndromes, high-output cardiac failure?

Answer 283

Pagets disease

Question 284

which clinical syndrome is associated with this pic?

Answer 284

Pagets, X-ray showing “cotton wool” appearance of the skull typical of Paget disease.

Question 285

what are rare tumors arising in the chromaffin cells of the adrenal medulla that secrete biogenic amines (norepinephrine, epinephrine, or dopamine) or their metabolites?

Answer 285

Pheochromocytomas are rare tumors arising in the chromaffin cells of the adrenal
medulla that secrete biogenic amines (norepinephrine, epinephrine, or dopamine) or
their metabolites.

Question 286

what other 3 conditions are associated with Pheochromocytoma?

Answer 286

Pheochromocytoma is associated with MEN2, von Hippel-Lindau disease, and
neurofibromatosis type 1.

Question 287

what is the preferred test to diagnose pheochromocytoma?

Answer 287

Twenty-four–hour urine measurements of metanephrines and catecholamines or
measurement of plasma metanephrines is preferred.

Question 288

after a positive urine in plasma test for pheochromocytoma, what should be done next in evaluation?

Answer 288

Positive biochemical tests are followed by abdominal and pelvic CT with contrast.

Question 289

what is the treatment of choice for Pheochromocytoma?

Answer 289

Surgery is the treatment of choice. Use phenoxybenzamine to control BP
preoperatively.

Question 290

for patients with pheochromocytoma, what cAN be used prior to surgery tp control BP?

Answer 290

Use phenoxybenzamine to control BP
preoperatively.

Question 291

WHAT IS THE DFFIERENCE IN TREATMENT TO CONTROL bp IN PATIENTS WITH A pheochromocytoma before surgery and during surgery?

Answer 291

Use phenoxybenzamine to control BP
preoperatively. Give IV normal saline to maintain intravascular volume; nitroprusside or

phentolamine is indicated for treating intraoperative hypertensive crisis.+

Question 292

For control of hypertension in patients with pheochromocytoma, should you first use α-
adrenergic blockers or β-adrenergic?

Answer 292

For control of hypertension in patients with pheochromocytoma, select α-
adrenergic blockers first. α-Adrenergic blockade before adequate β-adrenergic

blockade can result in severe paroxysmal hypertension.

Question 293

what is the difference in size between Pituitary microadenomas and
macroadenomas?

Answer 293

Pituitary adenomas are benign tumors that originate from one of the different anterior
pituitary cell types. They are classified based on size as microadenomas (<10 mm) or
macroadenomas (≥10 mm).

Question 294

what 2 things should be done for workup in asymptomatic patients with incidentally noted pituitary masses?

Answer 294

Most incidentally noted pituitary masses in asymptomatic patients are benign,
nonfunctional pituitary adenomas.
* Obtain dedicated pituitary MRI.
* Assess possible pituitary hypersecretion (measure prolactin and IGF-1).

Question 295

For patients with a pituitary mass, what should they be screened for regardless of symptoms?

Answer 295

Screen patients for hypopituitarism with pituitary tumors regardless of symptoms with
measurement of:
* FSH, LH
* cortisol
* TSH, T4
* total testosterone (men)

Question 296

which clinical syndrome is associated with Galactorrhea, amenorrheaand what should you measure ?

Answer 296

Prolactinoma Serum prolactin level

Question 297

which clinical syndrome is associated with Enlargement of hands, feet, nose, lips, or
tongue; increased spacing of teeth? what should be measured?

Answer 297

Acromegaly
Serum IGF-1
OGTT (fails to suppress GH)

Question 298

which clinical syndrome is associated with Proximal muscle weakness, facial rounding,
centripetal obesity, purple striae, diabetes
mellitus, and hypertension ? what should be measured?

Answer 298

Cushing
disease

24-Hour urine cortisol excretion, dexamethasone suppression test,
or late-night salivary cortisol level (elevated), serum ACTH level
(elevated or inappropriately “normal”)

Question 299

which syndrome is associated with A discrete area of hypolucency (arrow) is seen in an otherwise normal-sized pituitary
gland of homogeneous density?

Answer 299

Prolactinoma

Question 300

which clinical syndrome is associated with this pic?

Answer 300

Prolactinoma. A discrete area of hypolucency (arrow) is seen in an otherwise normal-sized pituitary
gland of homogeneous density.

Question 301

what is the preferred tx for symptomatic
prolactinoma?

Answer 301

Choose a dopamine agonist (cabergoline preferred to bromocriptine) for symptomatic
prolactinoma.

Question 302

when should surgery be considered in patients with pituaitary adenomas?

Answer 302

Choose surgery for adenomas secreting GH, ACTH, or TSH; for adenomas associated
with mass effect, visual field defects, or hypopituitarism; and for prolactinomas
unresponsive to dopamine agonists.

Question 303

when should observation be considered in patients with pituitary adenomas?

Answer 303

Choose observation for women with microprolactinoma and normal menses or for
patients with nonfunctioning pituitary microadenomas.

Question 304

which clinical syndrome is associated with hypopituitarism and, possibly, symptoms of a mass lesion, occur during or after pregnancy but may be the result of cancer immunotherapy with checkpoint inhibitors. ?

Answer 304

Lymphocytic hypophysitis

Question 305

which clinical syndrome is associated with obstetric hemorrhage and hypotension; and most
commonly presents with amenorrhea, a postpartum inability to lactate, and fatigue.?

Answer 305

Postpartum pituitary necrosis (Sheehan syndrome)

Question 306

which clinical syndrome is associated with results from sudden pituitary hemorrhage or infarction and is often associated with sudden headache, visual change, ophthalmoplegia, and altered mental status.?

Answer 306

Pituitary apoplexy

Question 307

what are the symptoms of posterior pituitary dysfunction?

Answer 307

The posterior pituitary releases vasopressin and oxytocin directly into the systemic
circulation.
Look for symptoms of posterior pituitary dysfunction:

• polydipsia, polyuria, and nocturia (DI secondary to ADH deficiency)

Question 308

Panhypopituitarism is a condition in which adequate production of all anterior pituitary
hormones is lacking, usually because of a large tumor (see Pituitary Adenomas
following), apoplexy, necrosis, autoimmune disorder, or complications of pituitary
surgery.
What is the treatments for Patients with panhypopituitarism.?

Answer 308

Patients with panhypopituitarism require daily thyroxine and cortisol replacement.

Question 309

What is the basis or measurement used for adjusting Thyroxine dosing for central hypothyroidism ?

Answer 309

• Thyroxine dosing for central hypothyroidism is based on serum free T4 rather
  than TSH levels.

Question 310

what is the next step in evaluation After documenting pituitary hormone deficiency?

Answer 310

After documenting pituitary hormone deficiency, select dedicated pituitary MRI.

Question 311

What is the most common cause of hirsutism with oligomenorrhea?

Answer 311

PCOS is the most common cause of hirsutism with oligomenorrhea.

Question 312

what syndrome is assoc with ovulatory dysfunction (amenorrhea, oligomenorrhea, infertility) and/or polycystic ovaries on ultrasound and laboratory or clinical evidence of hyperandrogenism (hirsutism, acne)

Answer 312

PCOS

Question 313

in a woman with acute onset of rapidly progressive hirsutism or virilization, what should be suspcted?

Answer 313

An androgen-secreting ovarian or adrenal tumor should be suspected in a
woman with acute onset of rapidly progressive hirsutism or virilization.

Question 314

What is a first-line intervention for PCOS?

Answer 314

Weight loss is a first-line intervention.

Question 315

FOR pcos, WHAT IS THE TX IF DM IS PRESENT?

Answer 315

Choose metformin for prediabetes/diabetes.

Question 316

iN Treatig PCOS, If fertility is not desired, what treatment for hirsutism and
regulation of menses should be added?

Answer 316

If fertility is not desired, choose oral contraceptive for treatment of hirsutism and
regulation of menses; can add spironolactone if hirsutism remains a problem.

Question 317

iN Treating PCOS, If fertility is desired, what treatment for hirsutism and
regulation of menses should be added?

Answer 317

If fertility is desired, ovulation can be induced with clomiphene citrate or letrozole.

Question 318

How should Women with a history of gestational diabetes be screened for DM?

Answer 318

Women with a history of gestational diabetes are at very high risk for developing
type 2 diabetes and require annual screening following delivery.

Question 319

WHAT 4 Antihypertensive agents can be safely used during pregnancy ?

Answer 319

Antihypertensive agents that can be safely used during pregnancy include
methyldopa, β-blockers (except atenolol), calcium channel blockers, and hydralazine.

Question 320

For treating osteoporosis, how long should you continue therapy with IV vs PO?

Answer 320

Stopping therapy after 3 years (IV
therapy) or 5 years (oral therapy) is reasonable in women who have a stable BMI, have
no history of fracture, and are at low risk for fracture.

Question 321

Which therapy for osteoporosis can lead to osteonecrosis of the jaw?

Answer 321

Drugs for osteoporosis have various adverse effects:

• IV bisphosphonate therapy and denosumab can lead to osteonecrosis of the jaw.

Question 322

Which therapy for osteoporosis can lead to esophagitis and atypical hip
fracture.?

Answer 322

• Oral bisphosphonate therapy may lead to erosive esophagitis and atypical hip
  fracture.

Question 323

what are testing indications for Primary hyperaldosteronism?

Answer 323

Testing indications are:
* untreated hypertension with sustained BP >150/100 mm Hg
* resistant hypertension (>140/90 mm Hg) with three-drug therapy including a
diuretic
* hypertension and an incidentally discovered adrenal mass
* hypertension associated with spontaneous or diuretic-induced hypokalemia
* hypertension in the setting of a first-degree relative with primary aldosteronism
* hypertension in the setting of family history of hypertension onset <40 years of
age

Question 324

How should you test for primary hyperaldosteronism?

Answer 324

Evaluate patients using simultaneous measurements of plasma aldosterone and plasma
renin activity. In patients taking an ACE inhibitor or an ARB, a nonsuppressed plasma
renin level rules out mineralocorticoid excess.

Question 325

what plasma aldosterone–plasma renin activity ratio and plasma aldosterone level
strongly suggests primary hyperaldosteronism?

Answer 325

A plasma aldosterone–plasma renin activity ratio >20, with a plasma aldosterone level
>15 ng/dL, strongly suggests primary hyperaldosteronism.

Question 326

how is a dx of primary hyperaldosteronism. confirmed?

Answer 326

The diagnosis is confirmed
by demonstrating nonsuppressibility of elevated plasma aldosterone in response to a
high salt load given intravenously or orally.

Question 327

In testing for primary hyperaldosteronism, all antihypertensive agents can be continued while testing except which ones?

Answer 327

Testing can be done in patients receiving treatment with all antihypertensive agents
except spironolactone and eplerenone, both of which antagonize the aldosterone
receptor.

Question 328

After autonomous hyperaldosteronism is diagnosed, what should be done next in evaluation?

Answer 328

After autonomous hyperaldosteronism is diagnosed, select CT of the adrenal glands.

Question 329

when diagnosing primary hyperaldosteronism, if the imaging is unrevealing, what test should be done before surgery and why?

Answer 329

Adrenal vein sampling is needed before surgery to confirm the source of aldosterone
secretion when imaging is unrevealing and to confirm lateralization when imaging
demonstrates an adrenal adenoma.

Question 330

what is the treatment of choice for adrenal hyperplasia vs aldosterone-producing adenoma?

Answer 330

Spironolactone or eplerenone is the treatment of choice for adrenal hyperplasia.
Laparoscopic adrenalectomy is indicated for an aldosterone-producing adenoma.

Question 331

which clinical syndrome is associated with the absence of menses for more than 3 months in
women who previously had regular menstrual cycles or 6 months in women who have
irregular menses?

Answer 331

Secondary amenorrhea is defined as absence of menses for more than 3 months in
women who previously had regular menstrual cycles or 6 months in women who have
irregular menses.

Question 332

what is the most common cause of secondary amenorrhea ?

Answer 332

Test all women with secondary amenorrhea for pregnancy, the most common cause.

Question 333

In testing for secondary amenorrhea, after pregnancy is ruled out, what should be tested next?

Answer 333

In the absence of pregnancy, assess hormonal status with estradiol, FSH, LH, TSH, and
prolactin levels.

Question 334

In testing for secondary amenorrhea, after pregnancy is ruled out, what should be tested next?

Answer 334

In the absence of pregnancy, assess hormonal status with estradiol, FSH, LH, TSH, and
prolactin levels.

Question 335

which clinical syndrome is associated with Low estradiol and low or inappropriately normal FSH and LH ?

Answer 335

Low estradiol and low or inappropriately normal FSH and LH indicate
hypogonadotrophic hypogonadism.

Question 336

In pts with Low estradiol and low or inappropriately normal FSH and LH and suspected
hypogonadotrophic hypogonadism what testing should be done next?

Answer 336

A progesterone challenge test is performed in these patients.
* No bleeding following a progesterone challenge indicates low estrogen because
of hypothalamic hypogonadism; measure estradiol level to confirm.

Question 337

what is the significance of no bleeding following a progesterone challenge?

Answer 337

• No bleeding following a progesterone challenge indicates low estrogen because
  of hypothalamic hypogonadism; measure estradiol level to confirm.

Question 338

what does bleeding following progesterone challenge indicate tell you about estrogen?

Answer 338

Bleeding following progesterone challenge indicates a normal estrogen state and
suggests possible hyperandrogenism (e.g., PCOS).

Question 339

which clinical syndrome is associated with Low estradiol and elevated FSH and LH levels?

Answer 339

Low estradiol and elevated FSH and LH levels indicate hypergonadotrophic
hypogonadism. Consider:
* premature ovarian insufficiency (autoimmune)
* chemotherapy
* pelvic radiation

Question 340

When a nodule is discovered, what is the first thing that should be checked?

Answer 340

When a nodule is discovered, assess thyroid function with a serum TSH level.

Question 341

When a nodule is discovered, and a Low TSH is seen, what should be seen next?

Answer 341

obtain radioisotope scan scintigraphy to confirm the diagnosis of autonomously functioning thyroid adenoma and to rule out additional
nonfunctioning nodules.

Question 342

When a nodule is discovered, and with normal or high TSH what should be done next?

Answer 342

Normal or high TSH → obtain ultrasonography.

Question 343

when is Fine-needle aspiration biopsy indicated for thyroid nodules >1 cm?

Answer 343

FNAB is indicated for:
* all thyroid nodules >1 cm with suspicious sonographic features and a normal
TSH level

Question 344

At what size thyroid nodule, is Fine-needle aspiration biopsy indicated in patient with cancerous risk factors or imaging findings?

Answer 344

FNAB is indicated for:
* nodules <1 cm in patients with risk factors for thyroid cancer or suspicious
ultrasound characteristics

Question 345

which clinical syndrome is associated with this pic?

Answer 345

A hyperfunctioning nodule is shown on the lateral aspect of the left thyroid lobe on
thyroid scan.

Question 346

When is Calcitonin measurement considered?

Answer 346

Calcitonin measurement is considered only in patients with hypercalcemia or a
family history of thyroid cancer or MEN2.

Question 347

How do you Treat hyperfunctioning solitary thyroid nodules ?

Answer 347

Treat hyperfunctioning solitary thyroid nodules with
radioactive iodine ablation or hemithyroidectomy.

Question 348

when is Surgery is indicated for patients with Thyroid Nodule:?

Answer 348

Surgery is indicated for patients with:
* continued nodule growth despite normal initial FNAB results
* nondiagnostic results on repeat FNAB
* malignant cytology
* large multinodular goiters with compressive symptoms

Question 349

In assessing serum levels of vitamin D, which type of vit D should be measured and is the
best indicator of vitamin D status?

Answer 349

In assessing serum levels of vitamin D, concentrations of 25-hydroxyvitamin D are the
best indicator of vitamin D status. The Institute of Medicine has determined that a vitamin D level of ≥20 ng/mL is
sufficient.

Question 350

In patients with metabolic alkalosis, what lab can differentiate saline-unresponsive (eg, primary hyperaldosteronism) from saline-responsive (eg, vomiting, recent diuretic use) causes?

Answer 350

In patients with metabolic alkalosis, urine chloride can differentiate saline-unresponsive (eg, primary hyperaldosteronism) from saline-responsive (eg, vomiting, recent diuretic use) causes. Urine chloride is low (<20 mEq/L) in saline-responsive cases.

Question 351

what level and number urine cl is associated with saline-responsive met alkalosis?.

Answer 351

Urine chloride is low (<20 mEq/L) in saline-responsive cases. Low urine CI- (<20 mEq/L), as in this patient, reflects the kidneys’ attempt to increase Cl- reabsorption in volume-depleted patients (ie, saline responsive).

Question 352

which met alkalosis is associated with High urine CI- (>20 mEq/L) and reflects renal wasting of CI- (ie, saline unresponsive)?

Answer 352

Hypervolemic etiologies include excess mineralocorticoid activity (eg, primary hyperaldosteronism), which causes hypertension (Choice
C). Hypovolemic etiologies include disordered renal handling of Na* and CI-(ie, Bartter and Gitelman syndromes).

Question 353

what met alk is associated with low urine cl-?

Answer 353

Metabolic alkalosis causes include surreptitious vomiting and Diuretic misuse. Difference is dieurrtic use has HIGH urine cl

Question 354

what are the Two laboratory features commonly present with hypomagnesemia ?

Answer 354

Two laboratory features commonly present with hypomagnesemia are hypocalcemia (40% of patients) and hypokalemia (60% of patients). Hypocalcemia is due to decreased parathyroid hormone (PTH) secretion and PTH resistance (impaired calcium mobilization from bone). Hypokalemia is due to renal potassium wasting. In a patient with hypomagnesemia, administration of potassium typically does not restore serum potassium concentration to normal until body magnesium stores are replenished.

Question 355

Serum ferritin levels >2500 ng/mL are highly
specific for this condition and reflect disease activity. what is the condition?

Answer 355

In Adult-Onset Still Disease, Serum ferritin levels >2500 ng/mL are highly
specific for this condition and reflect disease activity.

Question 356

which clinical syndrome is associated with quotidian fever (more than 3 weeks) in which the temperature usually spikes once daily and then
returns to subnormal
* fatigue, malaise, arthralgia, and myalgia
* proteinuria
* serositis
* evanescent pink rash
* joint manifestations include a nonerosive inflammatory arthritis

Answer 356

Adult-Onset Still Disease

Question 357

what is the treatment for mild vs severe Adult-Onset Still Disease?

Answer 357

NSAIDs are generally used as first-line agents in
management of mild disease; glucocorticoids are useful in patients with more severe
disease. Life-threatening disease is treated with glucocorticoids and an interleukin-1
receptor antagonist, such as anakinra or canakinumab.

Question 358

In Synovial Fluid Analysis, which category of inflammation is associated with a Leukocyte
count of >50,000/μL?

Answer 358

Infectious. Also has Positive Gram
stainb
; positive
culturec

Question 359

In Synovial Fluid Analysis, which category of inflammation is associated with a Leukocyte
count of 10,000-50,000 and positive crystals?

Answer 359

Crystal Induced

Question 360

In Synovial Fluid Analysis, which category of inflammation is associated with a Leukocyte
count of 2000-20,000/μL?

Answer 360

Inflammatory

Question 361

In Synovial Fluid Analysis, which category of inflammation is associated with a Leukocyte
count of 200-2000/μL?

Answer 361

Noninflammatory

Question 362

what is associated with Urate crystals, negatively birefringent vs those that are rhomboid,
positively birefringent;?

Answer 362

Gout crystals are shaped like a needle and are negatively birefringent. Pseudogout crystals are rhomboid shaped and positively birefingent