Endocrinology

Question 1

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

Answer 1

Papillary cancer

Question 2

is an add-on therapy to metformin to achieve improvement in hemoglobin A_1c level and weight loss.

Answer 2

Liraglutide (Victoza)

Note: potential concerns for development of pancreatitis and medullary thyroid carcinoma with GLP-1 receptor agonists. The patient does not have a personal or family history of these abnormalities to preclude use of liraglutide.

Question 3

The most common cause of primary adrenal insufficiency in the United States is autoimmune adrenalitis, and positive

Answer 3

21-hydroxylase antibodies are found in approximately 90% of those cases.

Question 4

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

Answer 4

Pituitary MRI obtained to evaluate for prolactinoma

Question 5

Treat primary adrenal insufficiency?

Answer 5

Hydrocortisone twice daily and fludrocortisone once daily (i.e. glucocorticoid and mineralocorticoid)

Question 6

a marker of increased bone turnover, should be measured after radiographic diagnosis of Paget disease of bone

Answer 6

Serum alkaline phosphatase

Question 7

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

Answer 7

Subacute thyroiditis

Question 8

___________________________ significantly prevents the development of clinical neuropathy and reduces nerve conduction and vibration threshold abnormalities in type 1 diabetes mellitus.

Answer 8

Enhanced glucose control

Question 9

Potent antiresorptive drugs (e.g. bisphosphonates) can cause severe hypocalcemia by impairing efflux of calcium from the skeleton in patients with?

Answer 9

Vitamin D deficiency; it is important to assess vitamin D levels and correct deficiency before beginning treatment with an antiresorptive drug.

Question 10

Signs of androgen excess such as progressive hirsutism and virilization over a short period of time in female patients suggest the diagnosis of?

Answer 10

an androgen-producing adrenal or ovarian tumor & a CT scan should be done/

Question 11

Is characterized by reduced serum T₃, low or low-normal serum T₄, and normal or low (but detectable) serum TSH levels around the time of a sickness/illness?

Answer 11

Nonthyroidal illness syndrome (euthyroid sick syndrome)

Question 12

Following adrenalectomy for Cushing syndrome, patients require daily

Answer 12

Glucocorticoid (e.g. Hydrocortisone) 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.

Question 13

In men with specific signs and symptoms of hypogonadism, measuring an

Answer 13

8 AM total testosterone level is indicated; if the testosterone level is low, a second 8 AM confirmatory testosterone level is measured.

Question 14

In chronic hypoparathyroidism, the goals of therapy are to eliminate symptoms while avoiding complications of therapy; monitoring

Answer 14

Urine calcium excretion is mandatory because hypercalciuria often limits therapy.

Question 15

Excluding glucocorticoid administration, the most common cause of adrenocorticotropic hormone (ACTH)-independent Cushing syndrome is

Answer 15

an adrenal tumor

Question 16

____________________________ is the most appropriate management of steroid-induced hypogonadism.

Answer 16

Cessation of anabolic steroid use

Question 17

For women with hypothyroidism adequately treated with levothyroxine before pregnancy, dosing can be empirically increased by

Answer 17

30% when pregnancy is confirmed (i.e taking an additional 2 tablets of their prepregancy Synthroid dose)

Question 18

Because gender-affirming hormone therapy limits fertility,

Answer 18

reproductive options should be discussed with patients prior to initiation

Question 19

Many medications cause falsely high levels of catecholamines or metanephrines including certain

Answer 19

antidepressants e.g Amitriptyline that inhibit norepinephrine uptake; therefore discontinuation of these agents at least 2 weeks prior to testing for pheochromocytoma is recommended

Question 20

For low-risk osteoporotic women, treatment with antiresorptive therapy for

Answer 20

5 years is sufficient

Question 21

Metformin may be continued in patients with an estimated glomerular filtration rate of

Answer 21

30 to 45 mL/min/1.73 m² after consideration of risks and benefits; if metformin is continued, frequent monitoring of kidney function (every 3 months) is recommended

Question 22

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

Answer 22

Oral contraceptive agents, that contain 30 to 35 µg of ethinyl estradiol appear to be more effective in managing hirsutism than formulations containing less ethinyl estradiol.

Question 23

In patients with pituitary tumors,

Answer 23

pituitary hypersecretion should be ruled out by biochemical testing

Question 24

prior to adrenalectomy for pheochromocytoma to prevent potential hypertensive crisis during anesthesia induction and/or manipulation of the tumor

Answer 24

An α-receptor blockade with phenoxybenzamine or another α-blocker

Note: Because phenoxybenzamine causes vasodilation, an expected consequence of therapy is postural hypotension. To counteract this and allow appropriate dose escalation of phenoxybenzamine, patients are advised to drink plenty of fluids, eat high salt-containing foods, and to make liberal use of the salt shaker at meal times.

Question 25

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

Answer 25

Empagliflozin

Question 26

After ruling out pregnancy, the initial laboratory evaluation in secondary amenorrhea includes

Answer 26

Measurement of follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels

Question 27

To manage in-patient hyperglycemia,

Answer 27

Scheduled basal insulin or basal insulin plus correction insulin is appropriate for patients who are fasting or who have poor oral intake.

Question 28

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.

Answer 28

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Question 29

Should be used to treat hyperprolactinemia in women with irregular periods who are trying to conceive.

Answer 29

Dopamine agonist therapy

Question 30

In persons with a family history of recurrent primary hyperparathyroidism and neuroendocrine tumors arising from the pancreas and tumors of the pituitary gland?

Answer 30

Multiple endocrine neoplasia syndrome 1 (MEN1)

Note: Primary hyperparathyroidism may be the first sign of MEN1

Question 31

Diagnose vitamin D-dependent hypercalcemia such as Sarcoidosis or lymphoma?

Answer 31

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

Question 32

Women with type 1 or type 2 diabetes mellitus who are planning pregnancy should be counseled on the risk of

Answer 32

development or progression of diabetic retinopathy; rapid improvements in glycemic levels during pregnancy can temporarily worsen preexisting retinopathy.

Note: Dilated eye examinations should occur before pregnancy or in first trimester if not done prior to pregnancy. Patients should be monitored every trimester and then closely for 1 year postpartum as indicated by the degree of retinopathy.

Question 33

Are recommended as first-line therapy in adult men and women on chronic glucocorticoid therapy with moderate to high fracture risk regardless of age?

Answer 33

Oral bisphosphonates

Question 34

Signs and symptoms of a _____________________________ 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.

Answer 34

Thyroid-stimulating hormone-secreting adenoma

Question 35

Symptomatic prolactinomas are treated with

Answer 35

Dopamine agonists e.g bromocriptine and cabergoline

Question 36

During the “honeymoon phase” of type 1 diabetes mellitus to reduce metabolic stress on functioning beta cells and preserve any residual function for as long as possible.

Answer 36

Continuing insulin, even at low doses, is recommended

Question 37

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

Answer 37

are not sustained when treatment is stopped; therefore Denosumab should be continued & not stopped after 5 years of treatment.

Question 38

In fasting hospitalized patients with type 1 diabetes mellitus,

Answer 38

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 39

In all patients with an adrenal mass that is clearly not an adenoma, even in the absence of typical symptoms or hypertension

Answer 39

Biochemical testing (i.e 24-hour metanephrines) for pheochromocytoma should be undertaken

Question 40

In patients with primary hyperparathyroidism who are undergoing parathyroidectomy surgery, identifying and correcting

Answer 40

Vitamin D deficiency (check 25-hydroxyvitamin D level) is important to avoid postoperative hypocalcemia, which occurs due to rapid flux of serum calcium into bone (hungry bone syndrome).

Question 41

Initial testing for subclinical Cushing syndrome is a

Answer 41

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

Question 42

Screen for Cushing syndrome in a patient with an alternate sleep schedule e.g. a night shift worker?

Answer 42

The 24-hour urine free cortisol test for Cushing syndrome is not impacted by either estrogen therapy or sleeping patterns.

Question 43

Gynecomastia can be an adverse effect of medications such as

Answer 43

spironolactone causes an imbalance between free estrogen and free androgen resulting in glandular breast tissue enlargement.

Question 44

Malabsorptive disorders such as ________________ may decrease levothyroxine absorption resulting in higher than expected levothyroxine dose requirements.

Answer 44

Celiac disease

Question 45

When evaluating infertility, both female and male factors should be considered concurrently; _____________ is part of the initial diagnostic evaluation.

Answer 45

Semen analysis

Question 46

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

Answer 46

Chronic opioid use

Question 47

The most common cause of primary amenorrhea is gonadal dysgenesis, most commonly associated with

Answer 47

Turner syndrome (45,X0)

Question 48

Evaluate postprandial hypoglycemia in a patient without diabetes with a history of Roux-en-Y gastric bypass?

Answer 48

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.

Question 49

Oral, injectable (including joint injections), and even topical glucocorticoids are able to suppress adrenocorticotropic hormone (ACTH) secretion and result in secondary adrenal insufficiency. How do you treat?

Answer 49

Hydrocortisone

Note: Fludrocortisone in addition to hydrocortisone is unwarranted as fludrocortisone is needed only in primary adrenal insufficiency. There is no mineralocorticoid deficiency in secondary adrenal insufficiency.

An early morning (8 AM) serum cortisol of less than 3 μg/dL (82.8 nmol/L) is consistent with cortisol deficiency, whereas values greater than 15 to 18 μg/dL (414.0-496.8 nmol/L) exclude the diagnosis

Question 50

Treat hypothyroidism with

Answer 50

weight-based replacement dose of levothyroxine (1.6 µg/kg lean body weight) is recommended

Question 51

Should be obtained once the diagnosis of Cushing syndrome is established to determine if it is ACTH dependent or ACTH independent.

Answer 51

ACTH measurement

Question 52

In patients receiving thyroxine replacement therapy, initiation of estrogen or raloxifene increases thyroxine-binding globulin levels whereas

Answer 52

testosterone reduces thyroxine-binding globulin levels; in either situation a change in thyroxine dosage may be required.

Question 53

Treatment for postmenopausal osteoporosis, which reduces the risk for spine, hip, and nonvertebral fractures, and are generally well tolerated with low risk for serious adverse effects.

Answer 53

Alendronate, risedronate, zoledronic acid, and denosumab

Question 54

This diabetic drug stimulate insulin secretion, and they pose risk for hypoglycemia?

Answer 54

Sulfonylureas e.g Glyburide (that has a long half life)

Question 55

Recognize medications that interfere with screening for primary aldosteronism

Answer 55

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 56

A hemoglobin A_1c goal of what is recommended for older adults with complex medical history and significant comorbidities?

Answer 56

7.5-8.0%

Question 57

Have been associated with the development of hypophysitis with most patients presenting with the combination of headache, pituitary enlargement, and hypopituitarism?

Answer 57

Checkpoint inhibitors such as nivolumab, ipilimumab, and pembrolizumab

Question 58

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)

Answer 58

Adrenalectomy

Question 59

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

Answer 59

Hypomagnesemia

Question 60

is considered to be safe in those with an estimate glomerular filtration rate (eGFR) greater than 45 mL/minute/1.73 m² and is contraindicated in those with an eGFR less than 30 mL/min/1.73 m²

Answer 60

Metformin

Question 61

First-line therapy for toxic adenoma is

Answer 61

Radioactive iodine (¹³¹I) therapy or surgery.

Note: Toxic adenoma & multinodular goiter are the second most common cause of hyperthyroidism overall & are most frequently seen in older adults. These autonomously functioning nodules synthesize & secrete thyroid hormones independent of TSH stimulation as a result of activating mutations of the TSH receptor or G_sα. They are usually large and can be easily palpated on examination.

Question 62

Should be performed at the time of diagnosis of type 2 diabetes:

Answer 62

Screening for dyslipidemia, hypertension, a dilated eye examination, spot urine albumin-creatinine ratio, and a comprehensive foot examination

Question 63

______________________________ may identify undetected hyperglycemia when preprandial blood glucose values are at target goal, but the hemoglobin A_1c is above goal.

Answer 63

Measuring postprandial blood glucose levels

Question 64

Patients with asymptomatic primary hyperparathyroidism require monitoring of serum calcium and creatinine every

Answer 64

6 to 12 months and bone mineral density of the lumbar spine, hip, and distal radius every 2 years.

Question 65

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

Answer 65

2 to 3 months

Question 66

Most patients with biochemically confirmed primary aldosteronism should undergo

Answer 66

Adrenal vein sampling to confirm the source of the hyperaldosteronism

Question 67

This 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

Answer 67

Ultrasound

Question 68

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

Answer 68

adjusted based on free thyroxine (T_<u>4</u>) levels with the goal of obtaining a value within the upper half of the normal reference range

Question 69

Treatment for hypoglycemic unawareness is to

Answer 69

Reduce the insulin dose and avoid hypoglycemia in order to provide the body an opportunity to restore the ability to detect hypoglycemia.

Question 70

Screening for osteoporosis in premenopausal women is

Answer 70

not indicated in the absence of risk factors.
Lifestyle counseling for osteoporosis prevention should be done instead.

Question 71

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

Answer 71

Stopping the drug and assessment of the neutrophil count

Question 72

An increased risk of diabetic ketoacidosis with mild to moderate glucose elevations has been associated with the use of all the approved

Answer 72

Sodium-glucose transporter-2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin).

Question 73

Secondary hypogonadism is characterized by low testosterone level and low or inappropriately normal serum luteinizing hormone and follicle-stimulating hormone concentrations; what’sthe next step?

Answer 73

MRI of the pituitary is typically performed to evaluate secondary hypogonadism in the absence of obvious reversible causes such as drugs.

Question 74

In patients with myxedema coma, treatment should include?

Answer 74

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. Although controversial, some experts suggest administering liothyronine concomitantly. Once clinically improved, the patient can be transitioned to oral levothyroxine.

Question 75

Can erroneously increase the hemoglobin A_1c level due to an increase in the proportion of older erythrocytes?

Answer 75

Iron-deficiency anemia

Question 76

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.

Answer 76

Lobectomy

Question 77

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

Answer 77

Diabetes insipidus

Question 78

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?

Answer 78

Thyroid storm

Question 79

Is first-line therapy for all patients with type 2 diabetes without contraindications.

Answer 79

Metformin

Question 80

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

Answer 80

Reduce the insulin infusion rate and add intravenous dextrose to prevent hypoglycemia

Question 81

Type 2 amiodarone-induced thyrotoxicosis (destructive thyroiditis) can be treated with

Answer 81

Moderate- to high-dose prednisone that can be gradually tapered over 1 to 3 months.

Question 82

______________________________ 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]).

Answer 82

An androgen-secreting ovarian tumor

Question 83

Demonstrates greater improvements in glycemic control and cardiovascular risk factors compared with optimized medical therapy and lifestyle modifications.

Answer 83

Metabolic surgery

Question 84

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.

Answer 84

Osteomalacia