Endocrine

Question 1

Adrenal incidentaloma screening test for function.

Answer 1

1) overnight dexamethasone suppression test
2) Serum urine catecholamines & metanephrines
3)Aldo/renin ratio

Question 2

Adrenal incidentaloma imaging feature of cancer

Answer 2

• larger than 4cm
• irregular inhemogenous morphology
• delayed contrast washout
• Greater than 20 HU

Question 3

Pituitary gland incidentaloma
<10mm “microadenoma”

Answer 3

If there are no clinical features of pituitary hormonal hyperfunction, then the most cost effective strategy is to measure only prolactin levels.

Small lesions (2-4 mm) require no further testing, while lesions 5-9 mm usually require follow-up MRI in 12 months to document a lack of growth

Question 4

Pituitary gland incidentaloma
>10mm “macroadenoma

Answer 4

Lesions > 10 mm should be evaluated with biochemical testing for both pituitary hormonal hyperfunction/hypofunction (e.g., Cushing’s, acromegaly, and prolactin) and formal visual field/acuity testing

Lesions without mass effect or hormonal dysfunction can be safely followed with periodic clinical, biochemical, and radiological evaluation

Question 5

Pituitary gland incidentaloma surgery indication

Answer 5

Surgery is considered for macroadenomas with hormonal dysfunction or tumor mass effect, except for prolactinoma where medical therapy is effective.

Question 6

Diabetic amyotrophy

Answer 6

-occurs in reasonably controlled diabetics. May not have other diabetes complications

Presentation:
1)Acute asymmetric focal onset of pain followed by weakness in the proximal leg
2) autonomic failure
3)greater than 10% weight loss

Question 7

Thyroid function post RAI

Answer 7

TSH remains suppressed for months after radioactive iodine ablative treatment. Further treatment decisions are based on total T3 and free T4 levels, patient symptoms, and clinical examination.

Question 8

Opioid related hypogonadism

Answer 8

Chronic opioid use leads to decreased gonadotropin-releasing hormone secretion, and is a common cause of hypogonadism. Patients can develop decreased libido and other manifestations of hypogonadism. Management options include discontinuation, dose reduction, or rotation of opioid types, or androgen replacement therapy.

Question 9

Hungry bone syndrome

Answer 9

Risk factors for developing hungry bone syndrome after parathyroidectomy include moderate-to-severe hyperparathyroidism with evidence of high bone turnover, older age, and renal dysfunction. Laboratory findings include low calcium, low phosphorus, low magnesium, and normal (or high) PTH levels.

Question 10

Levothyroxine in central hypothyroidism

Answer 10

Levothyroxine therapy in central hypothyroidism should be based on serum free T4 levels, with the dose adjusted to maintain T4 in the high-normal range. TSH in central hypothyroidism demonstrates minimal responsiveness to levothyroxine and may not rise in patients with inadequate replacement.

Question 11

Thyrotoxicosis with low RAI uptake

Answer 11

1)Painless thyroiditis (silent thyroiditis, lymphocytic thyroiditis, subacute lymphocytic thyroiditis & postpartum thyroiditis)

2)Subacute (de Quervain’s) thyroiditis (subacute granulomatous thyroiditis)

3)latrogenic (eg, lithium, amiodarone, iodine, interferon alpha, interleukin-2)

4)Factitious ingestion of levothyroxine (T4) &/or triiodothyronine (T3)

5)Struma ovari
6)Acute thyroiditis
7)Extensive thyroid cancer metastases

Question 12

Laryngospasm post thyroidectomy DDX

Answer 12

Laryngospasm causing inspiratory stridor after thyroidectomy is a medical emergency.
The timing of stridor after thyroidectomy can provide a clue to its cause.

A) If respiratory distress or stridor is apparent immediately upon extubation, bilateral recurrent laryngeal nerve injury is likely.

B) Stridor appearing within a few hours of surgery suggests possible wound hematoma with tracheal compression

C) Stridor appearing later, especially if preceded by paresthesias or muscle cramps, suggests hypocalcemia from transient hypoparathyroidism or inadvertent parathyroidectomy.

Question 13

HbA1c pitfalls

Answer 13

Hemoglobin A1c is vulnerable to changes in hemoglobin production and survival;

Conditions associated with reduced red blood cell survival (eg, hemoglobinopathies) can cause a misleadingly low A1c,

Conditions associated with reduced red blood cell production (eg, iron deficiency) cause a misleadingly high Alc.

In such cases, the underlying hematologic condition should be corrected and the Alc rechecked. Alternately, serum fructosamine, which measures glycation of serum proteins, can be ordered; this test estimates glycemic control over 6-8 weeks

Question 14

When to treat subclinical hypothyroidism

Answer 14

1) TSH greater than 10
2) Positive Anti-TPO
3) Goiter
4) Symptomatic
5) Pregnancy
6) Ovulatory dysfunction with infertility
7) Hypercholesterolemia

Question 15

Hypothyroidism and heart

Answer 15

Initial work-up of patients with chronic pericardial effusion includes a complete blood count, basic metabolic panel, thyroid function tests, anti-double stranded DNA antibodies, and complement levels

Question 16

Hyperthyroidism in elderly

Answer 16

Hyperthyroidism may present with apathy in older individuals. Shortness of breath, weight loss, and atrial fibrillation occur more commonly in older patients. Screening for hyperthyroidism should be done in older individuals presenting with new onset atrial fibrillation.

Question 17

Paget disease

Answer 17

Paget disease of bone can be asymptomatic or present with bone pain. Diagnosis is confirmed by radiographic abnormalities and elevated bone alkaline phosphatase. Bone scan can delineate the extent of disease and guide treatment. Bisphosphonates are the preferred treatment

Question 18

Statin side effects

Answer 18

Statins are associated with an increased risk of diabetes mellitus and worsening glycemic control in patients with established diabetes mellitus. However, this excess risk is significantly less than the reduction in risk for cardiovascular events

Question 19

Toxic adenoma and toxic multi nodular Goiter treatment

Answer 19

Patients with toxic adenoma or multinodular goiter who have overt hyperthyroidism (low TSH, increased T4) should have definitive treatment with radioactive iodine ablation or surgical thyroidectomy, rather than only symptomatic management

Unlike Graves disease, in which radioiodine ablation leads to postablative hypothyroidism, the radioactive iodine in nodular thyroid disease is taken up primarily in the abnormal tissue, with little damage to the surrounding healthy tissue. Following treatment, most patients are euthyroid

Question 20

Diabetes test discrepancy

Answer 20

The diagnosis of diabetes or prediabetes requires two abnormal test results from the same sample or in two separate test samples; when there is a discrepancy in screening test results, the abnormal test should be repeated.

Question 21

Hypogonadism in obese patients

Answer 21

In male patients with obesity, hypogonadism is best diagnosed by a free testosterone assessment because the total testosterone level may be affected by a decrease in the sex hormone–binding globulin level.

Question 22

Chronic hypoparathyroidism

Answer 22

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 23

Autoimmune polyglandular syndrome type 1

Answer 23

Autoimmune polyglandular syndrome type 1 is an inherited autosomal recessive disorder characterized by chronic mucocutaneous candidiasis, autoimmune hypoparathyroidism, and adrenal insufficiency.

Question 24

Autoimmune polyglandular syndrome type 2

Answer 24

Autoimmune polyglandular syndrome type 2 is associated with adrenal insufficiency (100%), chronic autoimmune thyroid disease (but occasionally Graves disease), type 1 diabetes mellitus, primary hypogonadism, and diabetes insipidus.

Question 25

Myxedema coma presentation

Answer 25

Myxedema coma (hypothyroid crisis) is characterized by altered mental status, hypothermia, hemodynamic instability, reduced cardiac output, and disordered breathing.

Specific signs may be absent, but myxedema (excess deposition of mucin in soft tissues) involving the face, tongue, and extremities is strongly suggestive. Diastolic hypertension and bradycardia can often be seen, and hypoglycemia is common (due to hypothyroidism or concurrent adrenal insufficiency).

Pre-existing hypothyroid symptoms are often present for several months before rapid clinical deterioration, which is often triggered by acute illness (eg, infection) or medication (eg, opioids

Question 26

Myxedema coma treatment

Answer 26

Myxedema coma is a life-threatening condition (30%-40% mortality), and treatment should be initiated without waiting for the results of thyroid function studies (serum TSH, free T4).

Most experts advise giving both levothyroxine (T4) and liothyronine (T3) intravenously until the patient’s condition stabilizes. Because adrenal insufficiency may coexist, patients with myxedema coma should also receive intravenous hydrocortisone until adrenal insufficiency is excluded by biochemical testing.

In addition, empiric broad-spectrum antibiotics should be considered as signs of infection are often suppressed.

Question 27

Hypoglycemia unawareness

Answer 27

• Hypoglycemia unawareness is characterized by insufficient release of counterregulatory hormones and an inadequate autonomic response to hypogly- cemia.

• A continuous glucose monitoring system can alert the patient to low glucose values in the absence of warn- ing symptoms and is a useful tool to reduce the frequency of hypoglycemic events in patients with hypoglycemia unawareness.

Question 28

Subclinical hyperthyroidism treatment

Answer 28

controversial: consider if TSH <0.1 mU/L and ↑ risk for CV disease or osteopenic

Question 29

Female infertility evaluation

Answer 29

Evaluation for causes of infertility is recommended for patients unable to achieve pregnancy after 12 months of consistent, unprotected intercourse; in women older than 35 years, evaluation of fertility is reasonable after 6 months of infertility.

• The first step in the workup of female infertility asso- ciated with normal menstrual cycles is to obtain a midluteal phase serum progesterone level

Question 30

Hypoglycemia tests

Answer 30

Post prandial Hypoglycemia diagnostic test of choice is Mixed meal test

Fasting Hypoglycemia diagnostic test of choice is 72 Hrs fasting.

Question 31

Atypical fracture with bisphosphonates

Answer 31

Atypical femoral fractures are a recognized complication of long-term bisphosphonate use. In such cases, stopping the bisphosphonate and switching to a bone anabolic agent like teriparatide, which promotes bone formation, is the preferred approach

Question 32

Infertility treatment for PCOS

Answer 32

1st line treatment is letrozole