Endocrine Flashcards by Kalaryn Fisher

A 20 year old female presents with a 6 week history of a painless, slowly growing
lump in her neck. On examination a lump is noted in the submental triangle of the
neck and moves up with tongue protrusion.
01. What is the most likely diagnosis?
1. Dermoid cyst
2. Lipoma
3. Thyroglossal cyst
4. Thyroid nodule
5. Reactive lymphadenopathy

Thyroglossal cyst

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a. submadibular
b. submantle
c. carioted
These make up the anterior triangle.

d. posterior triangle

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A 48 year old female presents with a 4 week history of a painless lump in her neck.
She has no other symptoms. On examination the lump was present in the lower
part of the anterior triangle of the neck in the midline and moves on swallowing.
Her TFT is normal.
02. What is the most appropriate next test in this patient?
1. Serum thyroglobulin
2. Ultrasound
3. 99m TC scan
4. CT chest
5. Serum calcitonin

Ultrasound

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papillary carcinoma of the thyroid therefore

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B - obstructive and toxic systems plus it s nodular

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hyperthyroidism
anxiety
pregnancy
drugs

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A 43 year old female presents to the GP with a 8 week history of a racing heart. No
PMH of note. On the combined oral contraceptive pill
Smokes 15 cigs/day; 2-3u alcohol 3X/week; 3 cups coffee/day
F/H- Sister has regular B12 injections
06. What further feature on history would be most consistent with a thyroid cause
for her palpitations?
A. Weight gain
B. Dry skin
C. Heat intolerance
D. Paresthesia
E. Headache

Heat intolerance

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m
On examination she appears anxious and thin. Her HR is 105 and irregular. Her BP is
145/70. Her CVS and Resp exams are normal. She has a palpable painless diffuse goitre.
A 43 year old female presents to the GP with a 8 week history of a racing heart. No
PMH of note. On the combined oral contraceptive pill
Smokes 15 cigs/day; 2-3u alcohol 3X/week; 3 cups coffee/day
F/H- Sister has regular B12 injections
What is the most likely diagnosis?
1. Grave’s disease
2. Toxic multinodular goitre
3. Thyroid adenoma
4. Subacute thyroiditis
5. Secondary hyperthyroidism

Graves disease

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A 43 year old female presents to the GP with a 8 week history of a racing heart. No
PMH of note. On the combined oral contraceptive pill
Smokes 15 cigs/day; 2-3u alcohol 3X/week; 3 cups coffee/day
F/H- Sister has regular B12 injections
What sign on ocular examination is most specific for Grave’s rather
than hyperthyroidism due to other causes?
1. Periorbital oedema
2. Lid retraction
3. Exophthalmos
4. Lid lag
5. Dilated pupils

Exophthalmos

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A 43 year old female presents to the GP with a 8 week history of a racing heart. No
PMH of note. On the combined oral contraceptive pill
Smokes 15 cigs/day; 2-3u alcohol 3X/week; 3 cups coffee/day
F/H- Sister has regular B12 injections
The appearance of her eyes on examination is shown.
09. What is the most likely pathogenesis of the exophthalmos?
1. Granulomatous inflammation
2. Fibroblast proliferation
3. Sympathetic overactivity
4. Neutrophilic inflammatory infiltrate

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Positive TRad

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A 43 year old female presents to the GP with a 8 week history of a racing heart. No
PMH of note. On the combined oral contraceptive pill
Smokes 15 cigs/day; 2-3u alcohol 3X/week; 3 cups coffee/day
F/H- Sister has regular B12 injections
What features are likely to be seen on histology if a biopsy was performed on this patient?
1. Follicular atrophy and inflammation
2. Plenty of lymphocytes & lymphoid follicles
3. Follicle hyperplasia & vacuolation of colloid
4. Lymphocytic inflammation & hyperplasia
5. Papillary structures with colloid vacuolation

Follicle hyperplasia & vacuolation of colloid

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A 43 year old female presents to the GP with a 8 week history of a racing heart. No
PMH of note. On the combined oral contraceptive pill
Smokes 15 cigs/day; 2-3u alcohol 3X/week; 3 cups coffee/day
F/H- Sister has regular B12 injections
What is the most appropriate initial treatment or definitive
treatment of her thyrotoxicosis?
1. Thyroidectomy
2. Radioiodine
3. B blocker
4. Carbimazole

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A 42 year old woman presents with a 3 month history of slight weight gain, irregular periods and fatigue despite getting adequate sleep. The fatigue is getting her down.
No PMH/Surgical history. On no medications,
Married, three children, works full time. Never smoked. Does not consume alcohol.
Family history: Mother (70) - Type 2 DM, Father (72) - Hypertension; both are well. All siblings well.
List 3 most likely differentials in this patient.

Menopause
diabetes
anemia
cancer
depression
hypothyroidism
OSA

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A 42 year old woman presents with a 3 month history of slight weight gain, irregular
periods and fatigue despite getting adequate sleep. The fatigue is getting her down.
No PMH/Surgical history
On no medications
Married, three children, works full time. Never smoked. Does not consume alcohol.
Family history: Mother (70) - Type 2 DM, Father (72) - Hypertension; both are well.
All siblings well.
13. What tool should be used to screen for depression in this patient?
1. K10
2. MMSE
3. Geriatric depression scale
4. Modified IMRIE score
5. HEADS screen

K10

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A 42 year old woman presents with a 3 month history of fatigue.
She has had irregular periods for 6/12 and associated weight gain.
She is not depressed when screened.
On examination: Vitals normal, small goitre noted, CVS, Resp, GI, Neuro NAD
14. Which of the following clinical sign is most commonly seen in hypothyroidism?
1. Alopecia
2. Hypercarotenemia
3. Dry skin
4. Delayed relaxation of reflexes
5. Loss of lateral eyebrows

Dry skin

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Increased LDL -

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Which of the following is an example of primordial prevention in
hypothyroidism?
1. Fortification of foods
2. Newborn screening
3. Early treatment with thyroxine
4. Interval monitoring of TFTs

Fortification of foods

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A 58 year old male presents with a 1 week history of headache, and blurred vision.
He is a non smoker and does not drink alcohol.
PMH- no known medical problems
FH: Mum had a stroke, dad had hypertension
On examination: Vitals BP 100/60, PR 80 bpm, regular, BMI 24, Temp 37.
Visual field defect was noted (shown below). No other focal neurological deficits.
Other systems examination was normal.
18. Where is the lesion?

Occipital cortex
Optic radiation
Optic chiasm
Optic nerve
Retina

Optic chiasm

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MRI head

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His imaging is shown below. His biochemical tests are normal.
He undergoes neurosurgical intervention.
He attends for a review 2 weeks post surgery. He complains of polyuria and
increased thirst.
20. What is most likely abnormality to be noted on his biochemical/urine test?
1. Hyponatraemia
2. Increased plasma osmolality
3. Increased urine osmolality
4. Glycosuria 3+
5. Urinary sodium 35 mmol/L

Diabetes insipidus
therefore increased plasma osmolarity

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What feature will make nephrogenic diabetes insipidus more likely
than a central cause?
High normal ADH level
Hypernatraemia
Decreased plasma osmolality
Low urine osmolality
Hyperglycaemia

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What is the most likely underlying cause for her symptoms? 1. Parathyroid adenoma 2. Sarcoidosis 3. Lymphoma 4. Paget’s disease 5. Metastatic breast cancer

presenting with suspected renal stone (IF HAVE PTH LEVEL) Parathyroid adenoma

What feature would make primary hyperparathyroidism more likely than secondary hyperparathyroidism? 1. Increased calcium 2. Elevated PTH 3. Increased phosphate 4. Reduced Vitamin D

Bryce is diagnosed with hypertension Bryce is 35 years old. He was recently discharged from the local hospital’s mental health unit. He was diagnosed with schizophrenia and commenced on clozapine. He reports some intermittent heart palpitations and constipation. Bryce lives with his partner Sam. Sam has been complaining more about his snoring and how sweaty Bryce gets at night time. Bryce works as a stockbroker and uses cocaine on the weekends. He goes to the gym 5 days a week. He drinks OTC protein shakes and sometimes injects steroids to help his training. He has lost 5kgs in the last 2 months. Bryce has a family history of Inflammatory Bowel Disease. Table talk Based on the history provided, what potential causes are there for Bryce’s Hypertension?

Secondary OSA Cocaine Steroids Protein shakes Hyperthyroidism Pheochromocytoma Medications? Primary Renal artery stenosis primary hyperaldosteronism

Bryce is 35 years old. He was recently discharged from the local hospital’s mental health unit. He was diagnosed with schizophrenia and commenced on clozapine. He reports some intermittent heart palpitations and constipation. Bryce lives with his partner Sam. Sam has been complaining more about his snoring and how sweaty Bryce gets at night time. Bryce works as a stockbroker and uses cocaine on the weekends. He goes to the gym 5 days a week. He drinks OTC protein shakes and sometimes injects steroids to help his training. He has lost 5kgs in the last 2 months. Bryce has a family history of Inflammatory Bowel Disease. On examination Bryce’s BP is moderately elevated. You also examine his fundi. 01. Which of the following retinal changes would be suggestive of chronic, poorly controlled hypertension? 1. Microaneurysms 2. Neovascularisation 3. Arteriovenous nipping 4. Vitreous haemorrhage 5. Roth’s spots

Arteriovenous nipping - having arteriosclerotic changes If sudden, would have haemorrhgnes, Diabetes would have micoaneurisms

After taking a thorough history and examination from Bryce, and excluding other causes, you suspect he may have primary hyperaldosteronism Bryce is 35 years old. He was recently discharged from the local hospital’s mental health unit. He was diagnosed with schizophrenia and commenced on clozapine. He reports some intermittent heart palpitations and constipation. Bryce lives with his partner Sam. Sam has been complaining more about his snoring and how sweaty Bryce gets at night time. Bryce works as a stockbroker and uses cocaine on the weekends. He goes to the gym 5 days a week. He drinks OTC protein shakes and sometimes injects steroids to help his training. He has lost 5kgs in the last 2 months. Bryce has a family history of Inflammatory Bowel Disease. 02. The most common cause of primary hyperaldosteronism is increased aldosterone from: A. Adrenal Adenoma B. Idiopathic bilateral hyperplasia C. Glomerulosa cells responsive to ACTH D. Adrenal carcinoma

Idiopathic bilateral hyperplasia

Primary hyperaldosteronism occurs at which site?

A - mineral corticoids Zona glomerulosa (aldosterone)

What would the most appropriate screening test in primary hyperaldosteronism? A. Morning cortisol B. Albumin: Creatinine Ratio C. Potassium level D. Corrected sodium level E. Aldosterone to Renin Ratio

Aldosterone to Renin Ratio

Whilst awaiting results of investigations. Bryce returns for review. He has checked his BP this morning and it was 182/90. 05. In which situation should Bryce be referred straight to the hospital for management? A. He has a mild headache and repeated systolic blood pressure measurements between 170-180 B. He reports decreased urination and has repeated diastolic blood pressure measurements between 110-120 C. He feels well and has repeated blood pressure measurements ranging from 180-190 systolic/ 100-110 diastolic

B. He reports decreased urination and has repeated diastolic blood pressure measurements between 110-120

Albert is 55 years old. He had a fall at home and sustained a Colles Fracture of the L wrist. Albert has become depressed and demoralized recently. He feels tired and he thinks his arm muscles have become a lot weaker, which he attributes to reduced mobility from the fracture. PMX: * BMI of 30 * Hypertension for 5 yrs. * For which he takes 3 medications. * Despite good medication compliance he struggles to get his BP below 150/90. * Diabetes for 5 years * managed on Metformin. * Asthma for 20 years * Managed on inhaled budesonide/formoterol and occasional oral prednisolone What historical features would alert you to the possibility of Cushing’s Syndrome and why?

Fracture muscular weakness hypertension resistant to medications BMI - metabolic syndrome taking oral steroids

Albert is 55 years old. He had a fall at home and sustained a Colles Fracture of the L wrist. Albert has become depressed and demoralized recently. He feels tired and he thinks his arm muscles have become a lot weaker, which he attributes to reduced mobility from the fracture. PMX: * BMI of 30 * Hypertension for 5 yrs. * For which he takes 3 medications. * Despite good medication compliance he struggles to get his BP below 150/90. * Diabetes for 5 years * managed on Metformin. * Asthma for 20 years * Managed on inhaled budesonide/formoterol and occasional oral prednisolone When examining Albert which finding would support your provisional diagnosis? A. Distal myopathy B. Hyperkeratosis C. Facial Pallor D. Interscapular fat pad

A. Distal myopathy - should be proximal B. Hyperkeratosis - thin skin C. Facial Pallor - plethora rather than pallor D. Interscapular fat pad Therefore is: D. Interscapular fat pad

Which of the following specimens of the adrenal gland would be seen in patients on long term corticosteroids?

A - atrophy B- normal c- hyperplasia

What test would you do initially if you suspect Albert has endogenous Cushing’s syndrome? A. 24 hour urinary cortisol B. Serum ACTH C. Morning serum cortisol

24-hour urine cortisol

A 59 year old male presents to the GP with a 24 hour history of dyspnoea and palpitations. He has a 1 week history of facial swelling and worsening fatigue for the past 6 weeks. He also has weight loss+, ↑ appetite. No cough/fever PMH: nil; meds: nil On Examination: Plethoric Large face + neck Pulse 100 bpm reg N volume BP 178/105 mm Hg Proximal myopathy Varicosities trunk Striae What biochemical abnormality is most likely in this patient? 1. Hypokalaemia 2. Hypoglycaemia 3. Hyponatremia 4. Hypocalcaemia 5. Metabolic acidosis

1. Hypokalaemia 2. Hypoglycaemia - should be hyper 3. Hyponatremia - should be hyper 4. Hypocalcaemia - should be hyper 5. Metabolic acidosis - should be alkalosis

A 59 year old male presents to the GP with a 24 hour history of dyspnoea and palpitations. He has a 1 week history of facial swelling and worsening fatigue for the past 6 weeks. He also has weight loss+, ↑ appetite. No cough/fever PMH: nil; meds: nil On Examination: Plethoric Large face + neck Pulse 100 bpm reg N volume BP 178/105 mm Hg Proximal myopathy Varicosities trunk Striae Relevant investigations are organised. His 24 hour urinary free cortisol is raised. His ACTH levels are elevated. Administration of high dose dexamethasone fails to cause ↓in cortisol levels. 10. What is the most likely underlying cause for the excess cortisol in this patient? 1. Lung tumour 2. Adrenal tumour 3. Pituitary tumour

Lung tumor - small cell Doxomethazone test negative therefore cannot be pituitary

Most common cause of Cushing’s syndrome is: 1. Lung tumour 2. Adrenal tumour 3. Pituitary tumour 4. Exogenous steroids 5. Familial

Exogenous steroids

Corticosteroids suppress the HPA axis. This is likely to result in a crisis on withdrawal of treatment. 12. This is more likely to happen in which of the following situations? 1. Short duration of steroid therapy(<1 week) 2. Prescription of multiple courses of high dose steroids 3. Only with oral steroid therapy 4. Steroids doses of 5 mg/day

Jess a 17 year old female presents with a 3 month history of worsening fatigue, lethargy, and an 8 kg weight loss. She has fainted several times. Her appetite is normal. No fever/night sweats Amenorrhoea past 2/12 PMH: nil FH: mother – hyperthyroidism; younger sib Type 1 diabetes On examination: Looks tired and wasted, BMI 16.8 BP 104/80 mmHg sitting 86/54 mm Hg standing Normal sexual development Pigmentation hands, axillae, palmar creases 13. What is the most likely diagnosis? 1. Hyperthyroidism 2. Phaeochromocytoma 3. Primary adrenal insufficiency 4. Latent Autoimmune Diabetes of Adults (LADA) 5. Anorexia Nervosa

Primary adrenal insufficiency

Jess a 17 year old female presents with a 3 month history of worsening fatigue, lethargy, and an 8 kg weight loss. She has fainted several times. Her appetite is normal. No fever/night sweats Amenorrhoea past 2/12 PMH: nil FH: mother – hyperthyroidism; younger sib Type 1 diabetes On examination: Looks tired and wasted, BMI 16.8 BP 104/80 mmHg sitting 86/54 mm Hg standing Normal sexual development Pigmentation hands, axillae, palmar creases Which of the following is the most common cause of the most likely diagnosis in this patient? 1. Congenital adrenal hyperplasia 2. Autoimmune Adrenalitis 3. Bilateral Adrenal Haemorrhage 4. Adrenal lymphoma 5. Pituitary disease

Autoimmune Adrenalitis

Jess a 17 year old female presents with a 3 month history of worsening fatigue, lethargy, and an 8 kg weight loss. She has fainted several times. Her appetite is normal. No fever/night sweats Amenorrhoea past 2/12 PMH: nil FH: mother – hyperthyroidism; younger sib Type 1 diabetes On examination: Looks tired and wasted, BMI 16.8 BP 104/80 mmHg sitting 86/54 mm Hg standing Normal sexual development Pigmentation hands, axillae, palmar creases He has autoimmune adrenalitis What is the most likely biochemical finding in this patient? 1. Decreased sodium 2. Increased glucose 3. Increased Aldosterone 4. Decreased ACTH 5. Decreased potassium

Decreased sodium

Jess a 17 year old female presents with a 3 month history of worsening fatigue, lethargy, and an 8 kg weight loss. She has fainted several times. Her appetite is normal. No fever/night sweats Amenorrhoea past 2/12 PMH: nil FH: mother – hyperthyroidism; younger sib Type 1 diabetes On examination: Looks tired and wasted, BMI 16.8 BP 104/80 mmHg sitting 86/54 mm Hg standing Normal sexual development Pigmentation hands, axillae, palmar creases He has autoimmune adrenalitis What is the pathophysiology of the hyperpigmentation seen in this patient? 1. Increased ACTH 2. Increased cortisol 3. Increased oestradiol 4. Increased adrenaline 5. Increased aldosterone

Increased ACTH

A 45 year old male (shown below) presents with a 1 month history of worsening headaches and increased sweating. PMH/PSH- nil. No H/o of hypercalcaemia or nephrolithiasis. F/H- H/o of hyperparathyroidism 17. What initial investigation would be most useful in this patient ? 1. IGF-1 level 2. CT brain 3. Blood glucose 4. Prolactin level 5. Calcium level

Most common cause of acromegaly is pituitary adenoma IGF-1 level Visual field test - bitemporal hemifeild Would do MRI

A 40 year old male presents with frequent headaches associated with flushing, sweating and palpitations. On examination his BP is 170/110 mmHg. 18. What is the most likely diagnosis? 1. Hyperthyroidism 2. Pheochromocytoma 3. Carcinoid syndrome 4. Obstructive sleep apnoea 5. Polycythaemia Rubra Vera

Pheochromocytoma- younger, severe hypertension and frequent attacks

A 40 year old male presents with frequent headaches associated with flushing, sweating and palpitations. On examination his BP is 170/110 mmHg. What investigation would confirm the most likely diagnosis in this patient? 1. ACTH levels 2. Cortisol levels 3. Adrenaline levels 4. Renin/aldosterone levels 5. Plasma metanephrine levels

Plasma metanephrine levels

A 40-year-old male presents with frequent headaches associated with flushing, sweating, and palpitations. On examination, his BP is 170/110 mmHg. You are concerned about Multiple Endocrine Neoplasia (MEN). 20. Which statement would be more suggestive of multiple endocrine neoplasia compared to sporadic endocrine tumors? 1. Common in older patients 2. Have a solitary focus 3. Usually inherited 4. Less aggressive 5. Less likely to recur

Usually inherited

Sheehan's syndrome is Post Partum necrosis of Posterior Pituitary gland. True False

F- anterior pituitary

Common deficiency of posterior pituitary function is, SIADH Diabetes Insipidus Sheehan's syndrome Nelsen Syndrome Addison's disease

Diabetes Insipidus

Commonest cause of Hyperpituitarism is, Gigantism Acromegaly Prolactinoma Cushing's disease Achandroplasia

Prolactinoma

Pituitary dwarfism is a "Proportional dwarf" True False

True

Dry & Brittle hair is characteristic feature of Graves Disease. True False

Pretibial myxedema is seen in both Graves & Hashimoto's disease. True False

Endemic cause of Cretinism is Iodine deficiency. True False

Clinically commonest thyroid disorder is Graves disease Hashimoto's disease Autoimmune thyroiditis Cretinism Papillary carcinoma

Graves

Commonest type of hypothyroidism clinically is, Primary Secondary Tertiary Central

Primary

Common thyroid disorder in aged (>45y) patients is Graves disease. True False

Hashimoto's disease can occur in children. True False

Characteristic Microscopic feature of Graves disease is, Plenty of lymphocytes Atrophic thyroid follicles Pale vacuolated colloid Lymphoid follicles. Dark red round colloid

Pale vacuolated colloid

Characteristic Microscopic feature of Hashimoto's disease is atrophic thyroid follicles with lymphocyte infiltration. True False

In a Multinodular Goitre, Typical Thyroid function status will be Hyperthyroidism Hypothyroidism Normal Thyroid function

Normal Thyroid function

Typcial pattern of radio iodine scan in a multinodular goitre is, Cold nodules Hot nodules Mixture of hot & cold nodules Uneven iodine uptake.

Uneven iodine uptake.

commonest cause of thyroid enlargement is, Adenoma Carcinoma MNG Thyroiditis

MNG

Chances of finding cancer in a solitary nodule of thyroid is approximately, 90% 10% 1% <1%

Commonest type of benign tumour of thyroid is a Multinodular Goitree. True False

Commonesst type of thyroid canceer in patients with endemic goitre is a follicular carcinoma. True False

Commonest disorder of parathyroid is an Adenenoma. True False

MEN type 1 is characterised by Medullary carcinoma of Thyroid. True False

Brown tumor of bone is a typical feature of Hypoparathyroidism. True False

Fungal Infections are typical component of APS type 1. True False

Multiple varying colored nodules in a thyroid specimen is typical of Toxic adenoma Follicular adenoma Multinodular goitre Hashimoto's disease Graves disease

Hemorrhage in the adrenal gland is typically seen in a patient with severe septicemia. True False

Single whitish nodule in the thyroid gland of a asymptomatic patient is typical of Multinodular goitre toxic adenoma Non functional adenoma Graves disease.

Non functional adenoma