Endocrinology

Question 1

When should you screen for T2DM?

Answer 1

Age 45, screen ever 3 yrs or earlier in high risk groups

Question 2

What is a sensitive indicator of thyroid function, it is generally recommended as a first-line test for thyroid disorders.

Answer 2

TSH

Question 3

weight of pituitary gland

Answer 3

~600g

Question 4

Blood supply of the posterior pituitary

Answer 4

The posterior pituitary is supplied by the inferior hypophyseal arteries

In contrast to the anterior pituitary, the posterior lobe is directly innervated by hypothalamic neurons (supraopticohypophyseal and tuberohypophyseal nerve tracts) via the pituitary stalk

Question 5

Lactotropes constitute __% of anterior pituitary cells

Answer 5

20

Question 6

Peak serum PRL levels (up to 30 μg/L) occur between ____ a.m.

Answer 6

4:00 and 6:00

Question 7

What makes prolactin unique among the pituitary hormones?

Answer 7

PRL is unique among the pituitary hormones in that the predominant hypothalamic control mechanism is inhibitory, reflecting tonic dopamine-mediated suppression of PRL release.

Question 8

In what instances does serum prolactin rise?

Answer 8

after exercise, meals, sexual intercourse, minor surgical procedures, general anesthesia, chest wall injury, acute myocardial infarction, and other forms of acute stress

Also increases (10 fold) during pregnancy then declines rapidly within 2 weeks of parturition

Question 9

What is the function of prolactin?

Answer 9

PRL acts to induce and maintain lactation and to suppress both reproductive function and sexual drive.

PRL inhibits reproductive function by suppressing hypothalamic (GnRH) and pituitary gonadotropin secretion and by impairing gonadal steroidogenesis in both women and men.

In the ovary, PRL blocks folliculogenesis and inhibits granulosa cell aromatase activity, leading to hypoestrogenism and anovulation.

PRL also has a luteolytic effect, generating a
shortened, or inadequate, luteal phase of the menstrual cycle. In men, attenuated LH secretion leads to low testosterone levels and decreased spermatogenesis.

These hormonal changes decrease libido and reduce fertility in patients with hyperprolactinemia.

Question 10

Most abundant anterior pituitary hormone

Answer 10

Growth hormone

Somatotrope -50%

Question 11

How does ghrelin affect GH?

Answer 11

Induces GHRH and GH release

Question 12

Peripheral target for GH

Answer 12

IGF-1

Question 13

Peak levels of GH secretion occurs when?

Answer 13

GH secretion is pulsatile, with highest peak levels occurring at night, generally correlating with sleep onset.

Question 14

In what instances does GH secretion increase?

Answer 14

Elevated GH levels occur within an hour of deep sleep onset as well as after exercise, physical stress, and trauma and during sepsis.

Question 15

What stimulates GH release?

Answer 15

GH is stimulated by oral ghrelin receptor agonists, intravenous l-arginine, dopamine, and apomorphine (a dopamine receptor agonist), as well as by α-adrenergic pathways.

β-Adrenergic blockade induces basal GH and enhances GHRH- and insulin-evoked GH release.

On the other hand, glucose decreases GH secretion

Question 16

Which organs express the highest amount of GH receptors?

Answer 16

The liver and cartilage express the greatest
number of GH receptors.

Question 17

Organ that is the major source of IGF-1

Answer 17

Liver

Question 18

What is the effect of IGF-1 on glucose levels

Answer 18

induces hypoglycemia and improves insulin sensitivity

Question 19

Peak time of ACTH secretion

Answer 19

ACTH secretion is pulsatile and exhibits a
characteristic circadian rhythm, peaking at about 6:00 a.m. and reaching a nadir about midnight

Question 20

What peptide regulates GnRH release?

Answer 20

Brain kisspeptin, a product of the KISS1 gene, regulates hypothalamic GnRH release

Question 21

syndrome that results from defective hypothalamic (GnRH) synthesis and is associated with anosmia or hyposmia due to olfactory bulb agenesis or hypoplasia

Answer 21

Kallman syndrome

Classically, the syndrome may also be associated with color blindness, optic atrophy, nerve deafness, cleft palate, renal abnormalities, cryptorchidism, and neurologic abnormalities such as mirror movements

Question 22

Syndrome characterized by intellectual disability, renal abnormalities, obesity, and hexadactyly, brachydactyly, or syndactyly

Answer 22

Bardet-Biedl Syndrome

Retinal degeneration begins in early childhood, and most patients are blind by age 30.

Question 23

Syndrome associated with hypogonadotropic hypogonadism, hyperphagia-obesity, chronic muscle hypotonia, mental retardation, and adult-onset diabetes mellitus

Answer 23

Prader Willi

Question 24

Hormone that is more likely to be affected by cranial irradiation

Answer 24

GH

GH deficiency is most common, followed by gonadotropin, thyroid, and ACTH deficiency

The development of hypopituitarism occurs over 5–15 years and usually reflects hypothalamic damage rather than primary destruction of pituitary cells.

Question 25

Lymphocytic hypophysitis occur most commonly in which subset of the population

Answer 25

post partum women

Most patients manifest symptoms of progressive mass effects with headache and visual disturbance.

The ESR often is elevated. Because it may be indistinguishable from a pituitary adenoma on MRI, hypophysitis should be considered in a postpartum woman with a newly diagnosed pituitary mass before an unnecessary surgical intervention is undertaken.

Question 26

Syndrome that occurs during post partum and presents with acute intrapituitary hemorrhagic vascular events can cause substantial damage to the pituitary and surrounding sellar structures.

Answer 26

Sheehan’s syndrome

Question 27

ACTH reserve is most reliably assessed by measuring

Answer 27

ACTH and cortisol levels during insulin-induced hypoglycemia

Administering insulin to induce hypoglycemia is contraindicated in patients with active coronary artery disease or known seizure disorders

Question 28

Syndrome with Homozygous or heterozygous mutations of the GH receptor are associated with partial or complete GH insensitivity and growth failure

Answer 28

(Laron syndrome)

Question 29

Short stature should be evaluated comprehensively if a patient’s height is > __ standard deviations below the mean for age or if the growth rate has decelerated

Answer 29

3

Question 30

Sequence of hormone loss in pituitary deficiency

Answer 30

The sequential order of hormone loss is usually GH → FSH/LH → TSH → ACTH.

Question 31

The most validated test to distinguish pituitary-sufficient patients from those with AGHD is

Answer 31

insulin-induced (0.05–0.1 U/kg) hypoglycemia

Question 32

Expected response of AGHD after insulin induced hypoglycemia

Answer 32

About 90% of healthy adults exhibit GH responses >5 μg/L; AGHD is defined by a peak GH response to hypoglycemia of <3 μg/L.

Contraindicated in patients with diabetes, ischemic heart disease, cerebrovascular disease, or epilepsy and in elderly patients.

Alternative stimulatory tests include intravenous arginine (30 g), GHRH (1 μg/kg), oral ghrelin receptor agonist (0.5 mg/kg), and glucagon (1 mg).

Question 33

Contraindications to GH therapy

Answer 33

Contraindications to therapy include the presence of an active neoplasm, intracranial hypertension, and uncontrolled diabetes and retinopathy

Women require higher doses than men, and elderly patients require less GH.

Question 34

Type of cholesterol increased by GH administration

Answer 34

HDL

Question 35

In ACTH deficiency, The total daily dose of hydrocortisone replacement preferably should generally not exceed _ mg daily, divided into two or three doses.

Answer 35

20

Question 36

most common presenting feature of adult hypopituitarism even when other pituitary hormones are also deficient.

Answer 36

Hypogonadism

Question 37

Screening test for
Acromegaly?
Prolactinoma?

Answer 37

See table

Question 38

Screening test for Cushing’s dse

Answer 38

See table

Question 39

Screening test for Gonadotropinoma

Answer 39

See table

Question 40

Screening test for TSH-producing adenoma

Answer 40

See table

Question 41

Transsphenoidal resection is the desired surgical approach for pituitary tumors, except for

Answer 41

rare invasive suprasellar mass surrounding the frontal or middle fossa or the optic nerves or invading posteriorly behind the clivus, which may require transcranial approaches.

Question 42

Treatment of choice for prolactinoma

Answer 42

Dopamine agonists

Question 43

Treatment for acromegaly

Answer 43

For acromegaly, somatostatin receptor ligands
(SRLs) and a GH receptor antagonist are indicated.

Question 44

______ are benign, suprasellar cystic masses that present with headaches, visual field deficits, and variable degrees of hypopituitarism. They are derived from Rathke’s pouch and arise near the pituitary stalk, commonly extending into the suprasellar cistern.

Answer 44

Craniopharyngiomas

Hypopituitarism is documented in ~90%, and diabetes insipidus occurs in ~10% of patients.

Question 45

Treatment for craniopharyngioma

Answer 45

Treatment usually involves transcranial or transsphenoidal surgical resection followed by postoperative radiation of residual tumor.

Question 46

the most common cause of pituitary hormone hypersecretion and hyposecretion syndromes in adults.

Answer 46

Pituitary adenomas

Question 47

Syndrome associated with Pituitary hyperplasia and adenomas (10%), Atrial myxomas, Schwannomas, Adrenal hyperplasia, Lentigines

Answer 47

Carney Complex

Question 48

autosomal dominant syndrome characterized primarily by a genetic predisposition to parathyroid, pancreatic islet, and pituitary adenomas

Answer 48

MEN 1

Question 49

syndrome that consists of polyostotic fibrous dysplasia, pigmented skin patches, and a variety of endocrine disorders, including acromegaly, adrenal adenomas, and autonomous ovarian function

Answer 49

McCune Albright

Question 50

most common pituitary hormone hypersecretion syndrome in both men and women

Answer 50

Hyperprolactinemia

Question 51

Effect of chronic renal failure on prolactin levels

Answer 51

Elevates by decreasing clearance

Question 52

the hallmarks of hyperprolactinemia in women.

Answer 52

Amenorrhea, galactorrhea, and infertility

Question 53

When is galactorrhea suspected in patients who just gave birth?

Answer 53

the inappropriate discharge of milk-containing fluid from the breast, is considered abnormal if it persists longer than6 months after childbirth or discontinuation of breast-feeding.

Question 54

In patients with markedly elevated PRL levels (____ μg/L), reported results may be falsely lowered because of assay artifacts;

Answer 54

> 1000

Question 55

Macroadenomas are >___ in diameter and may be locally invasive and impinge on adjacent structures.

Answer 55

1 cm

Tumor size generally correlates directly with PRL concentrations; values >250 μg/L usually are associated with macroadenomas.

Question 56

The drug Cabergoline effectively suppresses PRL for >___days after a single oral dose and induces prolactinoma shrinkage in most patients.

Answer 56

14

Question 57

Preferred dopamine agonists in pregnant patients

Answer 57

Bromocriptine

B for buntis

Question 58

What level of prolactin should you consider surgery in microadenoma

Answer 58

> 50 ug/L

Question 59

When should you repeat MRI after starting patient with macroadenoma on dopamine agonist?

Answer 59

4 months

Question 60

The most significant clinical impact of GH excess occurs with respect to the ____ system

Answer 60

cardiovascular

Question 61

Confirmatory test for acromegaly

Answer 61

The diagnosis of acromegaly is confirmed by demonstrating the failure of GH suppression to <0.4 μg/L within 1–2 h of an oral glucose load (75 g)

Question 62

Initial tx for acromegaly

Answer 62

Surgical resection of GH-secreting adenomas is the initial treatment for most patients

Transsphenoidal surgical resection by an experienced surgeon is the preferred primary treatment for both microadenomas (remission
rate ~70%) and macroadenomas (<50% in remission).

Question 63

Drug that antagonizes endogenous GH action by blocking peripheral GH binding to its receptor. Consequently, serum IGF-1 levels are suppressed, reducing the deleterious effects of
excess endogenous GH.

Answer 63

Pegvisomant

Question 64

Next step after surgery of acromegaly

Answer 64

Somatostatin receptor ligands eg. octreotide, lanreotide, pasireotide

Question 65

Account for 70% of patients with endogenous causes of Cushing’s syndrome.

Answer 65

Pituitary corticotrope adenomas (Cushing’s
disease)

Question 66

most common cause of cushingoid features

Answer 66

iatrogenic hypercortisolism

Question 67

Primary cause of death in Cushing’s syndrome

Answer 67

Cardiovascular

Question 68

Most common clinical feature of Cushing syndrome

Answer 68

Obesity and Thick skin

Question 69

Screening test for Cushing syndrome

Answer 69

24hr urinary free cortisol
Alternatively, overnight 1mg dexa test

Question 70

how do you differentiate ACTH secreting tumor vs ectopic ACTH secretion

Answer 70

see table

Question 71

Treatment of choice for cushing disease

Answer 71

Selective transphenoidal resection

The remission rate for this procedure
is ~80% for microadenomas but <50% for macroadenomas

Question 72

What is the effect of pasireotide on sugar levels

Answer 72

Notably, hyperglycemia and new-onset diabetes develop in up to 70% of patients, likely due to suppressed pancreatic secretion of insulin and incretins.

Question 73

What is an oral 11β-hydroxylase inhibitor used for Cushing dse that blocks adrenal gland cortisol biosynthesis, normalizes 24-h UFC in 86% of patients.

Answer 73

Osilodrostat (2 mg twice daily titrated up to 30 mg twice daily)

Elevated adrenal hormone precursors may lead
to hypokalemia and hypertension.

QTc prolongation and possibly
increased tumor volume are also reported.

Question 74

What is a drug used in Cushing syndrome that is a glucocorticoid receptor antagonist, blocks peripheral cortisol action and is approved to treat hyperglycemia in Cushing’s disease?

Answer 74

Mifepristone (300–1200 mg/d)

Because the drug does not target the pituitary tumor, both ACTH and cortisol levels remain elevated, thus obviating a reliable circulating biomarker.

Side effects are largely due to general antagonism of other steroid hormones and include hypokalemia, endometrial hyperplasia, hypoadrenalism, and hypertension.

Question 75

Drug that inhibits 11β-hydroxylase activity and normalizes plasma cortisol in up to 75% of patients with Cushing syndrome

Answer 75

Metyrapone (2–4 g/d)

Question 76

Adrenalectomy in the setting of residual corticotrope adenoma tissue predisposes to the development of _____ syndrome, a disorder characterized by rapid pituitary tumor enlargement and increased pigmentation secondary to high ACTH levels.

Answer 76

Nelson’s

Question 77

most common type of pituitary adenoma and are usually macroadenomas at the time of diagnosis

Answer 77

non functioning pituitary adenoma

Question 78

If PRL levels are <100 μg/L in a patient harboring a pituitary mass, what should be considered?

Answer 78

a nonfunctioning adenoma causing pituitary stalk compression should be considered

Question 79

Sources of ectopic ACTH secretion

Answer 79

Bronchial, abdominal carcinoid
Small-cell lung cancer
Thymoma

Question 80

critical first step in thyroid hormone synthesis.

Answer 80

Iodide uptake

Question 81

Mutation of the _____ gene causes Pendred syndrome, a disorder characterized by defective organification of iodine, goiter, and sensorineural deafness.

Answer 81

pendrin gene

Question 82

The Recommended Dietary Allowance (RDA) is
___ μg iodine per day for pregnant women and ____ μg iodine per dayfor breastfeeding women

Answer 82

220, 290

Question 83

Urinary iodine is > ___ in iodine-sufficient populations.

Answer 83

100 μg/L

Question 84

Excess iodide transiently inhibits thyroid iodide organification, a phenomenon known as the ____

Answer 84

Wolff-Chaikoff effect

Question 85

Five factors alter thyroid function in pregnancy

Answer 85

(1) the transient increase in hCG during the first trimester, which weakly stimulates the TSH-R
(2) the estrogen-induced rise in TBG during the first trimester, which is sustained during pregnancy
(3) alterations in the immune system, leading to the onset, exacerbation, or amelioration of an underlying autoimmune thyroid disease
(4) increased thyroid hormone metabolism by the placental type III deiodinase; and
(5) increased urinary iodide excretion, which can cause impaired thyroid hormone production in areas of marginal iodine sufficiency.

Question 86

Women with a precarious iodine intake (<___) are most at risk of developing a goiter during pregnancy or giving birth to an infant with a goiter and hypothyroidism.

Answer 86

50 μg/d

Question 87

Thyroid hormone requirements are increased by up to __% during pregnancy in levothyroxine-treated hypothyroid women.

Answer 87

45

Question 88

What are the differentiating factors of t3 vs t4

Answer 88

see table

Question 89

Medications that decrease conversion of T4 to T3

Answer 89

propranolol, ipodate, iopanoic acid,
amiodarone

Question 90

Expected TFT in thyroid hormone resistance

Answer 90

Increased unbound T4, T3
Normal or increased TSH

Individuals with RTH do not, in general, exhibit signs and symptoms that are typical of hypothyroidism because hormone resistance is partial and is compensated by increased levels of thyroid hormone.

Question 91

Large retrosternal goiters can cause venous distention over the neck and difficulty breathing, especially when the arms are raised _____

Answer 91

(Pemberton’s sign)

Question 92

What is the effect of biotin supplement on TSH levels

Answer 92

falsely low

Question 93

What is the effect of androgens and nephrotic syndrome on TBG

Answer 93

dec

Question 94

Serum Tg levels are increased in all types of thyrotoxicosis except

Answer 94

thyrotoxicosis factitia

Question 95

Sonographic findings that are highly suggestive of thyroid malignancy

Answer 95

Sonographic patterns that combine suspicious sonographic features are highly suggestive of malignancy (e.g., hypoechoic solid nodules with infiltrative borders and microcalcifications, >90% cancer risk)

Question 96

Sonographic findings that are highly suggestive of benign pattern of thyroid mass

Answer 96

(isoechoic solid nodules, 5–10% cancer risk).

Some patterns suggest benignity (e.g., spongiform nodules, defined as those with multiple small internal cystic areas, or simple cysts, <3% cancer risk)

Question 97

Starting dose for LT4 for congenital hypothyroidism

Answer 97

When the diagnosis is confirmed, T4
is instituted at a dose of 10–15 μg/kg per d,

Question 98

Most common symptom and sign of hypothyroidism

Answer 98

symptom: tiredness, weakness
sign: dry coarse skin, weak peripheral pulses

Question 99

Next step when TSH is high but FT4 is normal or low

Answer 99

Request for TPO antibodies

if symptomatic, consider LT4 tx
if symptomatic, annual ff up

Question 100

Dose of LT4 for clinical hypothyroidism

Answer 100

If there is no residual thyroid function, the daily replacement dose of LT4 is usually 1.6 μg/kg body weight (typically 100–150 μg), ideally taken at least 30 min before breakfast.

Question 101

when does symptoms of hypothyroidism resolve after treatment with LT4

Answer 101

Patients may not experience full relief from symptoms until 3–6 months after normal TSH levels are restored

Question 102

In patients of normal body weight who are taking ≥ ____ of LT4 per d, an elevated TSH level is often a sign of poor adherence to treatment.

Answer 102

200 μg

Question 103

What should be done if you missed 1 dose of LT4?

Answer 103

Because T4 has a long half-life (7 days), patients who miss a dose can be advised to take two doses of the skipped tablets at once

Question 104

When should subclinical hypothyroidism be treated

Answer 104

There are no universally accepted recommendations for the management of subclinical hypothyroidism, but LT4 is recommended if the patient is a woman who wishes to conceive or is pregnant or when TSH levels are >10 mIU/L.

Question 105

Target TSH in pregnant women

Answer 105

Because of the known increase in thyroid hormone requirements during pregnancy in hypothyroid women, LT4 therapy should be targeted to maintain a serum TSH in the normal range but <2.5 mIU/L prior to conception

Question 106

When should be TSH be checked during pregnancy?

Answer 106

thyroid function should be evaluated immediately after pregnancy is confirmed and every 4 weeks during the first half of the pregnancy, with less frequent testing after 20 weeks’ gestation (every 6–8 weeks depending on whether LT4 dose adjustment is ongoing).

Question 107

Elderly patients may require ___% LESS thyroxine than younger patients

Answer 107

20

In the elderly, especially patients with known coronary artery disease, the starting dose of LT4 is 12.5–25 μg/d with similar increments every 2–3 months until TSH is normalized

Question 108

How do you treat myxedema coma?

Answer 108

LT4 can initially be administered as a single IV bolus of 200–400 μg, which serves as a loading dose, followed by a daily oral dose of 1.6 μg/kg per d, reduced by 25% if administered IV

Because T4 → T3 conversion is impaired in myxedema coma, there is a rationale for adding liothyronine (T3 ) intravenously or via nasogastric tube to LT4 treatment, although excess liothyronine has the potential to provoke arrhythmias. An initial loading dose of 5–20 μg liothyronine should be followed by 2.5–10 μg every 8 h, with lower doses chosen for smaller or older patients and those at cardiovascular risk

Parenteral hydrocortisone (50 mg every 6 h) should be administered because there is impaired adrenal reserve in profound hypothyroidism

Question 109

Most common cause of thyrotoxicosis

Answer 109

Graves’ disease accounts for 60–80% of thyrotoxicosis

Question 110

_____ is a minor risk factor for Graves’ disease and a major risk factor for the development of ophthalmopathy

Answer 110

Smoking

Question 111

Most common symptom and sign of hyperthyroidism

Answer 111

symptom: hyperactivity, irritability, dysphoria
sign: tachycardia, AF in elderly

Question 112

Most common cardiovascular manifestation of Graves

Answer 112

The most common cardiovascular manifestation is sinus tachycardia, often associated with palpitations, occasionally caused by supraventricular tachycardia

Question 113

Where should you auscultate for thrill/bruit of thyroid in Grave’s dse

Answer 113

There may be a thrill or bruit, best detected at the inferolateral margins of the thyroid lobes, due to the increased vascularity of the gland and the hyperdynamic circulation

Question 114

Earliest manifestation of Grave’s ophthalmopathy

Answer 114

The earliest manifestations of ophthalmopathy are usually a sensation of grittiness, eye discomfort, and excess tearing

Question 115

_____ refers to a form of clubbing found in <1% of patients with Graves’ disease

Answer 115

Thyroid acropachy

Question 116

What is the site involved in thyroid dermopathy?

Answer 116

Thyroid dermopathy occurs in <5% of patients with Graves’ disease , almost always in the presence of moderate or severe ophthalmopathy. Although most frequent over the anterior and lateral aspects of the lower leg (hence the term pretibial myxedema), skin changes can occur at other sites, particularly after trauma.

The typical lesion is a noninflamed, indurated plaque with a deep pink or purple color and an “orange skin” appearance

Question 117

What should you suspect if TFTs revealed TSH normal or increased, high unbound T4

Answer 117

TSH-secreting pituitary adenoma or thyroid hormone resistance syndrome

Question 118

Next step when TSH is low but FT4 is normal

Answer 118

measure unbound t3

Question 119

When should you schedule ff up for subclinical hyperthyroidism

Answer 119

6-12 weeks

Question 120

Clinical course of Grave’s ophthalmopathy

Answer 120

The clinical course of ophthalmopathy does not follow that of the thyroid disease, although thyroid dysfunction can worsen eye signs. Ophthalmopathy typically worsens over the initial 3–6 months, followed by a plateau phase over the next 12–18 months, and then some spontaneous improvement, particularly in the soft tissue changes

Question 121

When should you follow up patients with hyperthyroidism after starting treatment

Answer 121

Thyroid function tests and clinical manifestations are reviewed 4–6 weeks after starting treatment, and the dose is titrated based on unbound T4 levels.

Most patients do not achieve euthyroidism until 6–8 weeks after treatment is initiated

Question 122

When should methimazole be stopped prior to RAI and when can it be restarted?

Answer 122

Carbimazole or methimazole must be stopped 2–3 days before radioiodine administration to achieve optimum iodine uptake and can be restarted 3–7 days after radioiodine in those at risk of complications from worsening thyrotoxicosis

Question 123

% risk of hypothyroidism after RAI

Answer 123

The risk of hypothyroidism after radioiodine depends on the dosage but is at 10–20% in the first year and 5% per year thereafter.

Question 124

How long shoud you avoid close prolonged contact with children and women after RAI

Answer 124

In general, patients need to avoid close, prolonged contact with children and pregnant women for 5–7 days because of possible transmission of residual isotope and exposure to radiation emanating from the gland

Question 125

What precautions should be done to avoid thyrotoxic crisis prior to thyroidectomy

Answer 125

Careful control of thyrotoxicosis with antithyroid drugs, followed by potassium iodide (SSKI; 1–2 drops orally tid for 10 days), is needed prior to surgery to avoid thyrotoxic crisis and to reduce the vascularity of the gland

Question 126

Birth defect associated with methimazole

Answer 126

Aplasia cutis

PTU should be used until 14-16 weeks

However, because of its rare association with hepatotoxicity, propylthiouracil should be limited to the first trimester and then maternal therapy should be converted to methimazole (or carbimazole) at a ratio of 15–20 mg of propylthiouracil to 1 mg of methimazole

Question 127

How do you manage thyroid storm

Answer 127

Large doses of propylthiouracil (500–1000 mg loading dose and 250 mg every 4 h) should be given orally or by nasogastric tube or per rectum; the drug’s inhibitory action on T4 → T3 conversion makes it the antithyroid drug of choice.

If not available, methimazole can be used in doses of 20 mg every 6 h.

One hour after the first dose of propylthiouracil, stable iodide (5 drops SSKI every 6 h) is given to block thyroid hormone synthesis via the Wolff-Chaikoff effect (the delay allows the antithyroid drug to prevent the excess iodine from being incorporated into new hormone).

Propranolol should also be given to reduce tachycardia and other adrenergic manifestations (60–80 mg PO every 4 h, or 2 mg IV every 4 h).

Question 128

Treatment for severe Grave’s ophthalmopathy

Answer 128

Pulse therapy with IV methylprednisolone (e.g., 500 mg of methylprednisolone once weekly for 6 weeks, then 250 mg once weekly for 6 weeks) is preferable to oral glucocorticoids, which are used for moderately active disease

Question 129

In children and young adults, the most common cause of acute thyroiditis

Answer 129

presence of a piriform sinus

usually due to a bacterial infection

Question 130

Other name for subacute thyroiditis

Answer 130

de Quervain’s thyroiditis, granulomatous thyroiditis, or viral thyroiditis

The patient usually presents with a painful and enlarged thyroid, sometimes accompanied by fever

Question 131

treatment for subacute thyroiditis

Answer 131

Relatively large doses of aspirin (e.g., 600 mg every 4–6 h) or nonsteroidal anti-inflammatory drugs (NSAIDs) are sufficient to control symptoms in many cases.

If this treatment is inadequate, or if the patient has marked local or systemic symptoms, glucocorticoids should be given. The usual starting dose is 15–40 mg of prednisone, depending on severity. The dose is gradually tapered over 6–8 weeks, in response to improvement in symptoms and the ESR

Question 132

What subset of population is silent thyroiditis associated?

Answer 132

Painless thyroiditis, or “silent” thyroiditis, occurs in patients with underlying autoimmune thyroid disease and has a clinical course similar to that of subacute thyroiditis. The condition occurs in up to 5% of women 3–6 months after pregnancy and is then termed postpartum thyroiditis

Question 133

Treatment for silent thyroiditis

Answer 133

Glucocorticoid treatment is not indicated for silent thyroiditis. Severe thyrotoxic symptoms can be managed with a brief course of propranolol, 20–40 mg three or four times daily. Thyroxine replacement may be needed for the hypothyroid phase but should be withdrawn after 6–9 months, as recovery is the rule

Question 134

The most common clinically apparent cause of chronic thyroiditis is ___________ , an autoimmune disorder that often presents as a firm or hard goiter of variable size

Answer 134

Hashimoto’s thyroiditis

Question 135

The most common hormone pattern in sick euthyroid syndrome (SES), also called nonthyroidal illness (NTI), is

Answer 135

a decrease in total and unbound T3 levels (low T3 syndrome) with normal levels of T4 and TSH.

Question 136

TFT abnormalities in the ff
Acute liver disease?
Acutely ill psyciatric patients?
HIV infection?
Renal disease?

Answer 136

Acute liver disease is associated with an initial rise in total (but not unbound) T3 and T4 levels due to TBG release

. A transient increase in total and unbound T4 levels, usually with a normal T3 level, is seen in 5–30% of acutely ill psychiatric patients. TSH values may be transiently low, normal, or high in these patients.

In the early stage of HIV infection, T3 and T4 levels rise, even if there is weight loss. T3 levels fall with progression to AIDS, but TSH usually remains normal.

Renal disease is often accompanied by low T3 concentrations, but with normal rather than increased rT3 levels, due to an unknown factor that increases uptake of rT3 into the liver

Question 137

Moreover, because amiodarone is stored in adipose tissue, high iodine levels persist for >___ months after discontinuation of the drug

Answer 137

6

Question 138

Most effective long term solution for amiodarone induced thyroiditis

Answer 138

thyroidectomy

Question 139

T/F

Thyroid function tests should be performed in all patients with goiter

Answer 139

True

to exclude thyrotoxicosis or hypothyroidism

Question 140

Low urinary iodine levels (____) support a diagnosis of iodine deficiency

Answer 140

<50 μg/L

Question 141

What are the UTZ findings suggestive of malignant thyroid mass in terms of composition, echogenicity, shape, margin and echogenic foci

Answer 141

Question 142

In patients with thyroid mass, Tracheal deviation is common, but compression must usually exceed ___ % of the tracheal diameter before there is significant airway compromise

Answer 142

70

Question 143

In hyperfunctioning solitary nodule, Thyrotoxicosis is usually mild and is generally only detected when a nodule is >____

Answer 143

3 cm

Question 144

Tx of choice for hyperfunctioning solitary nodule

Answer 144

RAI

Question 145

the most common malignancy of the endocrine system

Answer 145

Thyroid carcinoma

Question 146

Risk Factors for Thyroid Carcinoma in Patients with Thyroid Nodule from History and Physical Examination

Answer 146

Question 147

Activation of the _____ signaling pathway is seen in up to 70% of PTCs, although the types of mutations are heterogeneous

Answer 147

RET-RAS-BRAF

Question 148

Most common type of thyroid CA

Answer 148

PTCA

Question 149

T/F

Micrometastases is associated with poorer prognosis in PTCA

Answer 149

F

Micrometastases, defined as <2 mm of cancer in a lymph node, do not affect prognosis

However, gross metastatic involvement of multiple 2- to 3-cm lymph nodes indicates a 25–30% chance of recurrence and may increase mortality in older patients

Question 150

Therefore, near-total thyroidectomy is appropriate for tumors >___ or in the presence of metastases or clinical evidence of extrathyroidal invasion.

Answer 150

4 cm

Question 151

Mainstay of thyroid CA tx

Answer 151

Because most tumors are still TSH-responsive, LT4 suppression of TSH is a mainstay of thyroid cancer treatment

Question 152

Target TSH for PTCA with the ff risk
Low risk?
Intermediate ?
High?
Known mets?

Answer 152

low risk = 0.5–2.0 mIU/L
Intermediate = 0.1–0.5 mIU/L
high risk of recurrence and known mets <0.1 mIU/L

Question 153

Ideal TSH level before RAI for well differentiated thyroid CA

Answer 153

> 25 mIU/L

Question 154

sensitive marker of residual/recurrent thyroid cancer after ablation of the residual postsurgical thyroid tissue

Answer 154

Serum thyroglobulin

Question 155

Prognosis of anaplastic thyroid CA

Answer 155

The prognosis is poor, and most patients die within 6 months of diagnosis

Question 156

Most common type of lymphoma of the thyroid

Answer 156

DLBCL

highly sensitive to external radiation
Surgery should be avoided (may spread dse)

Question 157

which type of MEN has more aggresive form of MTC

Answer 157

MEN2B>2A

Question 158

Next step if FNAB showed follicular neoplasm

Answer 158

consider molecular testing

25–40% risk of malignancy

Question 159

Next step if FNAB showed Atypia or follicular lesion of undetermined significance

Answer 159

Repeat or consider molecular testing

~10–30% risk of malignancy

Question 160

In dibetes insipidus, The 24-h urine volume exceeds __mL/kg body weight, and the 24-h urine osmolarity is < ___ mosm/L

Answer 160

The 24-h urine volume exceeds 40 mL/
kg body weight, and the 24-h urine osmolarity is <280 mosm/L

Question 161

If symptoms of urinary frequency, enuresis, nocturia, and/or persistent thirst are present in the absence of glucosuria, the possibility of DI should be evaluated by

Answer 161

collecting a 24-h urine on unrestricted fluid intake

If the osmolarity is <280 mosm/L and the volume >50 mL/kg per day, the patient has DI and should be evaluated further to determine the type.

Question 162

Next step in evaluating for DI after 24 hr urine volume and osmolarity

Answer 162

Get the basal plasma AVP

Question 163

How do you differentiate primary polydipsia from pituitary DI

Answer 163

Pituitary bright spot is present in primary polydipsia since it reflects AVP stores

Question 164

When treating DI with desmoperessin, Hyponatremia rarely develops unless urine volume is reduced to < ____ per day or fluid intake is excessive due to an associated abnormality in thirst or cognition

Answer 164

10 mL/kg

Question 165

Treatment for hypodipsic hyponatremia

Answer 165

administering water orally if the patient is alert and cooperative or by infusing hypotonic fluids (0.45% saline or 5% dextrose and water) if the patient is not

Question 166

Most common form of SIADH

Answer 166

The most common is one in which the AVP secretion responds normally to osmotic stimulation and suppression but the threshold or set point of the system is lower than normal

Question 167

In SIADH, the excess body water should be eliminated. If the hyponatremia is mild and largely asymptomatic, restricting total water intake to ~_______ less than urine output for several days or until the syndrome remits spontaneously will usually suffice

Answer 167

30 mL/kg per day

Question 168

Alternative treatment for SIADH if water restriction does not suffice

Answer 168

Infusion of 3% saline at a rate of ~0.05 mL/kg body weight per min raises serum sodium at a rate of ~1–2 meq/L per h, not only by replacing the slight sodium deficit but also by promoting a solute diuresis, which reduces total body water.

Alternatively, a vaptan can be used to reduce body water by increasing urine output.

Question 169

Glucocorticoid excess is diagnosed by employing

Answer 169

dexamethasone suppression test.

Question 170

How do you assess glucorticoid deficiency

Answer 170

to assess glucocorticoid deficiency, ACTH stimulation of cortisol production is used

Question 171

How is ACTH stimulation done?

Answer 171

The standard ACTH stimulation test involves administration of cosyntropin (ACTH 1-24), 0.25 mg IM or IV, and collection of blood samples at 0, 30, and 60 min for cortisol.

A normal response is defined as a cortisol level >15–20 μg/dL (>400–550 nmol/L) 30–60 min after cosyntropin stimulation, with the precise cutoff dependent on the assay used

Question 172

How is insulin tolerance test done?

Answer 172

The ITT involves administration of regular insulin 0.1 U/kg IV (dose should be lower if hypopituitarism is likely) and collection of blood samples at 0, 30, 60, and 120 min for glucose, cortisol, and growth hormone (GH), if also assessing the GH axis.

Oral or IV glucose is administered after the patient has achieved symptomatic hypoglycemia (usually plasma glucose <40 mg/dL).

A normal response is defined as a cortisol >20 μg/dL and GH >5.1 μg/L, again with assay-specific cutoff variability.

Question 173

Cortisol is inactivated to cortisone by this microsomal enzyme

Answer 173

11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2)

Cortisol and aldosterone bind the mineralocorticoid receptor (MR) with equal affinity; however, cortisol circulates in the bloodstream at about a 1000-fold higher concentration.

Thus, only rapid inactivation of cortisol to cortisone by 11β-HSD2 prevents MR activation by excess cortisol, thereby acting as a tissue-specific modulator of the MR pathway

Question 174

Ectopic ACTH production is predominantly caused by occult carcinoid tumors, most frequently in the ___

Answer 174

lung, but also in thymus or pancreas.

Question 175

Screening tests for Cushings syndrome

Answer 175

Question 176

Next step after having positive screening test for Cushing syndrome

Answer 176

Get ACTH level

Question 177

Cutoff ACTH value for distinguishing ACTH dependent from independent Cushing

Answer 177

Question 178

Next step after confirming ACTH INdependent Cushings

Answer 178

CT of the adrenals

Question 179

Next step after confirming ACTH dependent Cushings

Answer 179

Question 180

For ACTH-dependent cortisol excess, ______ is the investigation of choice

Answer 180

magnetic resonance image (MRI) of the pituitary
but it may not show an abnormality in up to 40% of cases because of small tumors below the sensitivity of detection

Question 181

Oral agents with established efficacy in Cushing’s syndrome are

Answer 181

metyrapone and ketoconazole

Metyrapone inhibits cortisol synthesis at the level of 11β-hydroxylase , whereas the antimycotic drug ketoconazole inhibits the early steps of steroidogenesis

Question 182

most common cause of mineralocorticoid excess is

Answer 182

primary aldosteronism

Question 183

The clinical hallmark of mineralocorticoid excess is

Answer 183

hypokalemic hypertension

Question 184

Diagnostic screening for mineralocorticoid excess is not currently recommended for all patients with hypertension but should be restricted to those who

Answer 184

exhibit hypertension associated with drug resistance
hypokalemia
an adrenal mass
or onset of disease before the age of 40 years

Question 185

How long should you hold MR antagonists before doing ARR?

Answer 185

4 weeks

Question 186

What is a positive ARR

Answer 186

ARR screening is positive if the ratio is >750 pmol/L per ng/mL per hour, with a concurrently high normal or increased aldosterone

Question 187

What are the confirmatory tests for mineralocorticoid excess

Answer 187

The most straightforward is the saline infusion test, which involves the IV administration of 2 L of physiologic saline over a 4-h period.

Failure of aldosterone to suppress <140 pmol/L (5 ng/dL) is indicative of autonomous mineralocorticoid excess.

Alternative tests are the oral sodium loading test (300 mmol NaCl/d for 3 days) or the fludrocortisone suppression test (0.1 mg q6h with 30 mmol NaCl q8h for 4 days);

Question 188

Next step when Primary aldosteronism is confirmed but CT of adrenals is normal and with family of early onset hypertension

Answer 188

Dexa 0.125-0.5 mg/day

Question 189

What age should adrenal vein sampling be done in px with primary aldosteronism and unilateral adrenal mass?

Answer 189

> 40

Question 190

Screening test for incidentaloma

Answer 190

Question 191

CT scan features of an incidentaloma that makes it likely malignant

Answer 191

Tumor >= 4cm and >=20 HU

Question 192

Patients with confirmed ACC and successful removal of the primary tumor should receive adjuvant treatment with ______, particularly in patients with a high risk of recurrence as determined by tumor size >8 cm, histopathologic signs of vascular invasion, capsule invasion or violation, and a Ki67 proliferation index ≥10%

Answer 192

mitotane (o,p’DDD)

Adjuvant mitotane should be continued for at least 2 years, if side effects are tolerated. Regular monitoring of plasma mitotane levels is mandatory (therapeutic range 14–20 mg/L; neurotoxic complications more frequent at >20 mg/L).

Mitotane is usually started at 500 mg tid, with stepwise increases to a maximum dose of 2000 mg tid in days (high-dose saturation) or weeks (low-dose saturation) as tolerated.

Question 193

Most common cause of adrenal insufficiency

Answer 193

Hypothalamic-pituitary origin of disease

Question 194

Most common cause of primary adrenal insufficiency

Answer 194

autoimmune adrenalitis

Question 195

Electrolyte abnormalities present in primary adrenal insufficiency

Answer 195

adrenal insufficiency and is found in 80% of patients at presentation. Hyperkalemia is present in 40% of patients at initial diagnosis.

Question 196

Confirmatory test for adrenal insufficiency

Answer 196

The diagnosis of adrenal insufficiency is established by the short cosyntropin test

The cutoff for failure is usually defined at cortisol levels of <450–500 nmol/L (16–18 μg/dL) sampled 30–60 min after ACTH stimulation;

Question 197

Next step when adrenal insufficiency is confirmed

Answer 197

Once adrenal insufficiency is confirmed, measurement of plasma ACTH is the next step

Question 198

Treatment for acute adrenal insufficiency

Answer 198

Acute adrenal insufficiency requires immediate initiation of rehydration, usually carried out by saline infusion at initial rates of 1 L/h with continuous cardiac monitoring.

Glucocorticoid replacement should be initiated by bolus injection of 100 mg hydrocortisone, followed by the administration of 200 mg hydrocortisone over 24 h, preferably by continuous infusion or alternatively by bolus IV or IM injections.

Mineralocorticoid replacement can be initiated once the daily hydrocortisone dose has been reduced to <50 mg because at higher doses hydrocortisone provides sufficient stimulation of MRs.

Question 199

At what level of hydrocortisone requirement can you start the patient with acute adrenal insufficiency with mineralocorticoid replacement?

Answer 199

Mineralocorticoid replacement can be initiated once the daily hydrocortisone dose has been reduced to <50 mg because at higher doses hydrocortisone provides sufficient stimulation of MRs.

Mineralocorticoid replacement in primary adrenal insufficiency should be initiated at a dose of 100–150 μg fludrocortisone.

Question 200

Supraphysiologic glucocorticoid treatment with doses equivalent to _____ hydrocortisone or more will affect bone metabolism, and these patients should undergo regular bone mineral density evaluation

Answer 200

30 mg

Question 201

How is adequacy of treatment with mineralocorticoid replacement in px with acute adrenal insufficiency be measured

Answer 201

The adequacy of treatment can be evaluated by measuring blood pressure, sitting and standing, to detect a postural drop indicative of hypovolemia. In addition, serum sodium, potassium, and plasma renin should be measured regularly. Renin levels should be kept in the upper normal reference range

Question 202

Next diagnostic step when primary adrenal insufficiency is confirmed

Answer 202

Adrenal autoantibodies

Question 203

Next diagnostic step when secondary adrenal insufficiency is confirmed

Answer 203

MRI of the pituitary

Question 204

the most common syndromic cause of obesity

Answer 204

Prader-Willi syndrome (PWS)

Question 205

Cancers associated with obesity

Answer 205

The largest effects are on colorectal, kidney, and pancreatic cancer, adenocarcinoma of the esophagus, and, in women, endometrial carcinoma

Question 206

For obese patietns it is recommended to initiate treatment with a calorie deficit of _____ compared with the patient’s habitual diet

Answer 206

500–750 kcal/d

Alternatively, a diet of 1200–1500 kcal/d for women and 1500–1800 kcal/d for men (adjusted for the individual’s body weight) can be prescribed

Question 207

How is very low calorie diet defined?

Answer 207

The primary purpose of a VLCD is to promote a rapid and significant (13- to 23-kg) short-term weight loss over a 3- to 6-month period. The proprietary formulas designed for this purpose typically supply ≤800 kcal, 50–80 g of protein, and 100% of the recommended daily intake for vitamins and minerals

Question 208

When is surgery indicated in obese patients?

Answer 208

Question 209

MOA of Lorcaserin for weight loss

Answer 209

5-HT2C receptor agonist

Question 210

Orlistat is a synthetic hydrogenated derivative of a naturally occurring lipase inhibitor, lipostatin, that is produced by the mold

Answer 210

Streptomyces toxytricini.

Question 211

Definition of moderate and severe obesity

Answer 211

severe obesity (BMI ≥40 kg/m2 ) or for those with moderate obesity (BMI ≥35 kg/m2 )

Question 212

the most commonly undertaken and most accepted bypass procedure for obesity

Answer 212

Roux-en-Y

Question 213

Criteria for diagnosing DM

Answer 213

Question 214

How frequent should a person diagnsed with GDM be worked up for DM

Answer 214

ADA recommends that women with a history of GDM undergo lifelong screening for the development of diabetes or prediabetes at least every 3 years

Question 215

Criteria for screening for T2DM

Answer 215

Question 216

useful marker of insulin secretion and allows discrimination of endogenous and exogenous sources of insulin in the evaluation of hypoglycemia

Answer 216

C peptide

Question 217

Glucose levels > ____ mmol/L or ____ mg/dK stimulate insulin synthesis

Answer 217

3.9 mmol/L (70 mg/dL)

Question 218

The major susceptibility gene for type 1 DM is located in the HLA region on chromosome ___ .

Answer 218

6

Question 219

Most prominent gene that is a variant of the _____that has been associated with both type 2 DM and IGT in several populations

Answer 219

transcription factor 7-like 2 gene

Question 220

The ADA suggests that metformin be considered in individuals with both IFG and IGT who are at very high risk for progression to diabetes (age <__ years, BMI ≥__ kg/m2, and women with a history of GDM)

Answer 220

60 yrs
BMI >=35

Question 221

When should you screen for distal symmetric polyneuropathy in patients with DM?

Answer 221

The ADA recommends annual screening for distal symmetric polyneuropathy beginning with the initial diagnosis of diabetes and annual screening for autonomic neuropathy 5 years after diagnosis of type 1 DM and at the time of diagnosis of type 2 DM. This testing is aimed at detecting loss of protective sensation (LOPS) caused by diabetic neuropathy

mnemonic: T2DM–> 2day mo na itest

Question 222

Is nephropathy considered micro or macrovascular complication of DM?

Answer 222

microvascular

Question 223

Recommended BP for px with T2DM

Answer 223

The American Diabetes Association (ADA) recommends blood pressure control <130/80 mmHg for individuals with high cardiovascular risk and <140/90 mmHg for individuals with lower cardiovascular risk.

Question 224

hallmark of proliferative diabetic retinopathy

Answer 224

The appearance of neovascularization in response to retinal hypoxemia is the hallmark of proliferative diabetic retinopathy

Question 225

When should you screen for albuminuria for px with T2DM

Answer 225

commence 5 years after the onset of type 1 DM and at the time of diagnosis of type 2 DM

basically same timeline with dx dystal symmetric neuropathy

Question 226

The ADA suggests a protein intake of _____ in individuals with diabetic kidney disease.

Answer 226

0.8 mg/kg of body weight/day

Question 227

In px with DM, Nephrology consultation should be considered when the estimated GFR is <____ or with atypical features such as hematuria, rapidly declining renal function, or proteinuria > 3 g/day.

Referral for transplant evaluation should be made when the GFR approaches _____

Answer 227

30 mL/min per 1.743 m2

20 mL/min per 1.73 m2

Question 228

Most commonly involved CN in DM neuropathy

Answer 228

CN III

Question 229

The most prominent GI symptoms for DM neuropathy are

Answer 229

delayed gastric emptying (gastroparesis) and altered small- and large-bowel motility (constipation or diarrhea).

Question 230

treatment for DM cystopathy

Answer 230

Diabetic cystopathy should be treated with scheduled voiding or self-catheterization.

Question 231

Class of DM drugs that cannot be used for CHF

Answer 231

TZD

Question 232

A possible increased risk of lower limb amputation and Fournier’sgangrene has been reported with what type of OHAS

Answer 232

SGLT-2 inhibitor therapy.

Question 233

most common pattern of dyslipidemia in DM

Answer 233

The most common pattern of dyslipidemia is hypertriglyceridemia and reduced HDL cholesterol levels.

Question 234

Statin of choice in px with renal dse

Answer 234

Atorvastatin

Question 235

Providers should consider screening for asymptomatic PAD in individuals >50 years of age who have diabetes and other risk factors using _____

Answer 235

ankle-brachial index testing

Question 236

The most common skin manifestations of DM are ____ and ___and are usually relieved by skin moisturizers.

Answer 236

xerosis and pruritus

Question 237

What constitutes the Whipples triad of hypoglycemia?

Answer 237

Whipple’s triad: (1) symptoms consistent with hypoglycemia, (2) a low plasma glucose concentration measured with a precise method, and (3) relief of symptoms after the plasma glucose level is raised.

Question 238

When hypoglycemia is prolonged beyond ~___, cortisol and growth hormone also support glucose production and restrict glucose utilization to a limited amount (both mechanisms are reduced by ~80% compared to epinephrine).

Answer 238

~4h

Thus, cortisol and growth hormone play no role in defense against acute hypoglycemia.

Question 239

What is the primary secondary and third defense against hypoglycemia

Answer 239

Question 240

Many other drugs have been associated with hypoglycemia. These include commonly used drugs such as ______

Answer 240

angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists, β-adrenergic receptor antagonists, quinolone antibiotics, indomethacin, quinine, and sulfonamides.

Question 241

what is the IGFII to IGF I ratio in non beta cell tumor that cause hypoglycemia

Answer 241

The tumors are usually apparent clinically, plasma ratios of IGF-II to IGF-I are high, and free IGF-II levels (and levels of pro-IGF-II [1–21]) are elevated.

Question 242

Critical diagnostic findings in insulinoma

Answer 242

Critical diagnostic findings are a plasma insulin concentration ≥3 μU/mL (≥18 pmol/L), a plasma C-peptide concentration ≥0.6 ng/ mL (≥0.2 nmol/L), and a plasma proinsulin concentration ≥5.0 pmol/L when the plasma glucose concentration is <55 mg/dL (<3.0 mmol/L) with symptoms of hypoglycemia.

A low plasma β-hydroxybutyrate concentration (≤2.7 mmol/L) and an increment in plasma glucose level of >25 mg/dL (>1.4 mmol/L) after IV administration of glucagon (1.0 mg) indicate increased insulin (or IGF) actions

Question 243

Treatment for insulinoma

Answer 243

Surgical resection of a solitary insulinoma is generally curative.

Diazoxide, which inhibits insulin secretion, or octreotide can be used to treat hypoglycemia in patients with unresectable tumors

everolimus, an mTOR inhibitor, has also been successful in combination with the above approaches

Question 244

Treatment for hypoglycemia

Answer 244

If the patient is able and willing, oral treatment with glucose tablets or glucose-containing fluids, candy, or food is appropriate. A reasonable initial dose is 15–20 g of glucose. If the patient is unable or unwilling (because of neuroglycopenia) to take carbohydrates orally, parenteral therapy is necessary. IV administration of glucose (25 g) should be followed by a glucose infusion guided by serial plasma glucose measurements. If IV therapy is not practical, SC or IM glucagon (1.0 mg in adults) can be used, particularly in patients with T1DM.

oral glucose –> IV glucose –> SC/IM glucagon

Question 245

Symptoms of diabetes usually resolve when the plasma glucose is < ______, and thus most DM treatment focuses on achieving the second and third goals.

Answer 245

<11.1 mmol/L (200 mg/dL)

Question 246

What are the treatment goals for DM?

Answer 246

Question 247

To avoid exercise-related hyper- or hypoglycemia, individuals with type 1 DM should (1) monitor blood glucose before, during, and after exercise
(2) delay exercise if blood glucose is ______ and ketones are present
(3) if the blood glucose is ____ , ingest carbohydrate before exercising
(4) monitor glucose during exercise and ingest carbohydrate as needed to prevent hypoglycemia
(5) decrease insulin doses (based on previous experience) before and after exercise and inject insulin into a nonexercising area
(6) learn individual glucose responses to different types of exercise.

Answer 247

(2) >14 mmol/L (250 mg/ dL)
(3) <5.0 mmol/L (90 mg/dL)

In individuals with type 2 DM, exercise-related hypoglycemia is less common but can occur in individuals taking either insulin or insulin secretagogues.

Question 248

Frequency of SMBG monitoring in px with T1DM or T2DM

Answer 248

> 3x/day

Question 249

In patients achieving their glycemic goal, the ADA recommends measurement of the HbA1c at least _____

Answer 249

twice per year.

Question 250

Longest acting insulin

Answer 250

Degludec

Question 251

Short-acting insulin analogues should be injected just before (______) and regular insulin (____) prior to a meal. Sometimes short-acting insulin analogues are injected just after a meal (gastroparesis, unpredictable food intake

Answer 251

<10 min

30–45 min

Question 252

Highest Hba1c reduction

Answer 252

Biguanides and sulfonylureas

Question 253

OHAS associated with pancreatitis

Answer 253

GLP 1 agonists

Question 254

OHAS associated with inc risk of hyperkalemia

Answer 254

SGLT 2 inh

Question 255

OHAS associated with elevated LFT

Answer 255

a glucosidase inhibitor

Question 256

OHAS associated with Angioedema/urticarial and immune-mediated dermatologic effects

Answer 256

DPP4 inhibitor

Question 257

OHAS associated with CHF

Answer 257

Thiozolidinediones

** also contraindicated in hepatic insuffiency

Question 258

OHAS associated with Vit B12 deficiency

Answer 258

Biguanides

Question 259

OHAS that can cause weight gain

Answer 259

TZD and Insulin secretagogues

Question 260

Contraindications to alpha glucosidase inhibitor

Answer 260

These agents should not be used in individuals with inflammatory bowel disease, gastroparesis, or a serum creatinine >177 μmol/L (2 mg/dL)

Question 261

Effect of TZD on lipid profile

Answer 261

Rosiglitazone raises low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides slightly. (Lipid profile rose sa rosi-glitazone)

Pioglitazone raises HDL to a greater degree and LDL a lesser degree but lowers triglycerides

Question 262

SGLT 2 inhibitor assoc with inc risk of bladder CA

Answer 262

dapagliflozin

Question 263

Individuals who require >____ per day of long-acting insulin should be considered for combination therapy with metformin a GLP-1 receptor agonist, or a thiazolidinedione as these can reduce insulin requirements in some individuals with type 2 DM.

Answer 263

1 unit/kg

Question 264

The ADA clinical guidelines state that metabolic surgery should be considered in individuals with type 2 DM and a body mass index > kg/m2 if hyperglycemia is inadequately controlled despite optimal medical therapy

Answer 264

30

Question 265

How do you differentiate DKA vs HHS vs euglycemic DKA

Answer 265

See table

Question 266

Formula for corrected Na

Answer 266

(1.6-mmol/L [1.6-meq] reduction in serum sodium for each 5.6-mmol/L [100-mg/dL] rise in the serum glucose)

Question 267

Why do you shift fluid to 0.45 saline in DKA

Answer 267

The change to 0.45% saline or using lactated Ringer’s helps to reduce the trend toward hyperchloremia later in the course of DKA

Question 268

When should long acting insulin be administered in tx patients with DKA?

Answer 268

Long-acting insulin, in combination with SC short-acting insulin, should be administered as soon as the patient resumes eating, because this facilitates transition to an outpatient insulin regimen and reduces length of hospital stay.

It is crucial to continue the insulin infusion or insulin SC until adequate insulin levels are achieved by administering long-acting insulin by the SC route. Even relatively brief periods of inadequate insulin administration in this transition phase may result in DKA relapse

Question 269

In euglycemic DKA associated with SGLT2 inhibitors, the pharmacologic effect may persist for____ days following discontinuation of SGLT2 inhibitor therapy as evidenced by ongoing glucosuria despite normoglycemia (glucose <180 mg/dL), during which time relapse of ketoacidosis is common if nutritional intake has not advanced (e.g., in the postoperative setting).

Answer 269

10–14

Question 270

Hyperglycemia usually improves at a rate of ______ per h as a result of insulin-mediated glucose disposal, reduced hepatic glucose release, and rehydration.

Answer 270

4.2–5.6 mmol/L (50–100 mg/dL)

Question 271

When the plasma glucose reaches ______ , glucose should be added to the 0.45% saline infusion to maintain the plasma glucose in the 8.3–11.1 mmol/L (150–200 mg/dL) range, and the insulin infusion should be continued at a lower rate to inhibit ketogenesis

Answer 271

11.1– 13.9 mmol/L (200–250 mg/dL)

More rapid correction of the serum glucose can precipitate the development of cerebral edema

Question 272

When may bicarbonate be given in DKA?

Answer 272

in the presence of severe acidosis (arterial pH <7.0), sodium bicarbonate (50 mmol [meq/L] in 200 mL of sterile water with 10 meq/L KCl per h) may be administered for the first 2 h until the pH is >7.0

Question 273

In DKA, If the serum phosphate is <_____, then phosphate supplement should be considered and the serum calcium monitored

Answer 273

0.32 mmol/L (1 mg/dL)

Question 274

Glycemic goals in inpx according to ADA

Answer 274

.The ADA suggests the following glycemic goals for hospitalized patients: (1) in critically or non–critically ill patients: glucose of 7.8–10.0 mmol/L or 140–180 mg/dL; (2) in selected patients: glucose of 6.1–7.8 mmol/L or 110–140 mg/dL with avoidance of hypoglycemia; (3) the target range in the perioperative period should be 80–180 mg/dL (4.4–10.0 mmol/L)

Question 275

Insulin infusion is the preferred method for managing patients with type 1 DM over a prolonged (several hours) perioperative period or when serious concurrent illness is present (______u/h of regular insulin)

Answer 275

0.5–1.0 units

Question 276

If new-onset hyperglycemia remains during chronic treatment with supraphysiologic doses of glucocorticoid (>___ mg of prednisone or equivalent), the DM may be called “steroid-induced diabetes.”

Answer 276

5

Question 277

Current recommendations advise screening for glucose intolerance between weeks ____ of pregnancy in women not known to have diabetes

Answer 277

24 and 28

Question 278

What constitutes the harmonizing definition of metabolic syndrome?

Answer 278

Question 279

The most accepted and unifying hypothesis
to describe the pathophysiology of the metabolic syndrome

Answer 279

insulin resistance

Question 280

what in the lipid profile is an excellent marker of insulin resistance

Answer 280

hyperTAG

The other major lipoprotein disturbance in the metabolic syndrome is a reduction in HDL cholesterol.

Question 281

How much in % does fibrate decrease TAG

Answer 281

30-45%

Question 282

How much in % does nicotinic acid decrease TAG

Answer 282

20-35%

Question 283

only currently available drug with predictable
HDL cholesterol–raising properties

Answer 283

Nicotinic acid

nicotinic acid can increase HDL cholesterol by up to 30% above baseline

Question 284

Formula for corrected Calcium

Answer 284

An algorithm to correct for protein changes adjusts the total serum calcium (in mg/dL) upward by 0.8 times the deficit in serum albumin (g/dL) or by 0.5 times the deficit in serum immunoglobulin (in g/dL).

Question 285

Effect of aluminum hydroxide on Phosphate absorption

Answer 285

Decreased

Question 286

Effect of dec ph in calcium absorption

Answer 286

inc

Question 287

when should be phosphate measured?

Answer 287

basal, fatsing state due to wide variation throughout the day

Question 288

Dent’s disease is an X-linked recessive disorder caused by inactivating mutations in ____ , a chloride transporter expressed in endosomes of the proximal tubule;

Answer 288

CLCN5

features include hypercalciuria, hypophosphatemia, and recurrent kidney stones

Question 289

Respiratory failure and cardiac dysfunction, which are reversible with phosphate treatment, may occur at serum phosphate levels of ____

Answer 289

0.5–0.8 mmol/L (1.5–2.5 mg/dL).

Question 290

What is the rate of phosphate infusion in patients with hypophosphatemia?

Answer 290

See table

Hypocalcemia, if present, should be corrected before administering IV phosphate

Question 291

Hyperphosphatemia, defined in adults as a fasting serum phosphate concentration >____, usually results from impaired glomerular filtration, hypoparathyroidism, excessive delivery of phosphate into the ECF (from bone, gut, or parenteral phosphate therapy), or a combination of these factors

Answer 291

1.8 mmol/L (5.5 mg/dL)

Question 292

What is the treatment for hyperphosphatemia?

Answer 292

> Volume expansion may enhance renal phosphate clearance.
Aluminum hydroxide antacids or sevelamer may be helpful in chelating and limiting absorption of offending phosphate salts present in the intestine.
Hemodialysis is the most effective therapeutic strategy and should be considered early in the course of severe hyperphosphatemia, especially in the setting of renal failure and symptomatic hypocalcemia

Question 293

Hypomagnesemia usually signifies substantial depletion of body magnesium stores (___mmol/kg)

Answer 293

0.5–1

Question 294

What is the disadvantage of giving IV MgSO4 over MgCl2 in correcting for hypomagnesemia

Answer 294

MgSO4 may be given IV instead of MgCl2 , although the sulfate anions may bind calcium in serum and urine and aggravate hypocalcemia

Question 295

How is hypomagnesemia treated?

Answer 295

Mild, asymptomatic hypomagnesemia may be treated with oral magnesium salts (MgCl2 , MgO, Mg[OH]2 ) in divided doses totaling 20–30 mmol/d (40–60 meq/d).

More severe hypomagnesemia should be treated parenterally, preferably with IV MgCl2 , which can be administered safely as a continuous infusion of 50 mmol/d (100 meq Mg2+/d) if renal function is normal.

If GFR is reduced, the infusion rate should be lowered by 50–75%.

Question 296

How frequent should you repeat serum magnesium monitoring while correcting for hypomagnesemia

Answer 296

aSerum magnesium should be monitored at intervals of 12–24 h during therapy, which may continue for several days because of impaired renal conservation of magnesium (only 50–70% of the daily IV magnesium dose is retained) and delayed repletion of intracellular deficits, which may be as high as 1–1.5 mmol/kg (2–3 meq/kg

Question 297

The most prominent clinical manifestations of hypermagnesemia are vasodilation and neuromuscular blockade, which may appear at serum magnesium concentrations >__ mmol/L (>_ meq/L; > _ mg/dL)

Answer 297

2 mmol/L (>4 meq/L; >4.8 mg/dL)

Question 298

How is hypermagnesemia treated?

Answer 298

Vigorous IV hydration should be attempted, if appropriate. Hemodialysis is effective and may be required in patients with significant renal insufficiency.

Calcium, administered IV in doses of 100–200 mg over 1–2 h, has been reported to provide temporary improvement in signs and symptoms of hypermagnesemia

Question 299

The most specific screening test for vitamin D deficiency in otherwise healthy individuals is a ______

Answer 299

serum 25(OH)D level.

Question 300

The National Academy of Medicine has defined vitamin D sufficiency as a vitamin D level >____, although higher levels may be required to optimize intestinal calcium absorption in the elderly and those with underlying disease states, including obesity

Answer 300

50 nmol/L (>20 ng/mL)

Question 301

In patients who are vitamin D replete and are taking adequate calcium supplementation, the 24-h urinary calcium excretion should be in the range of ____ mg/24 h

Answer 301

100–250

Levels >250 mg/24 h predispose to nephrolithiasis and should lead to a reduction in vitamin D dosage and/or calciums supplementation

Question 302

Most common cause of hypercalcemia

Answer 302

hyperparathyroidism

If hypercalcemia has been manifest for >1 year, malignancy can usually be excluded as the caus

Question 303

Second most common cause of hypercalcemia

Answer 303

malignancy

Question 304

When the calcium level is >_____ calcification in kidneys, skin, vessels, lungs, heart, and stomach occurs, and renal insufficiency may develop, particularly if blood phosphate levels are normal or elevated due to impaired renal excretion.

Severe hypercalcemia, usually defined as ≥ _______can be a medical emergency; coma and cardiac arrest can occur

Answer 304

3.2 mmol/L (12.8 mg/dL)

3.7–4.5 mmol/L (14.8–18.0 mg/dL)

**factor is 4 in converting mmol to mg/dL

Question 305

The distinctive bone manifestation of hyperparathyroidism is ____

Answer 305

osteitis fibrosa cystica

Question 306

Indications for surgery in asymptomatic primary hyperparathyroidism

Answer 306

Question 307

What tests should be requested for monitoring primary hyperparathyroidism

Answer 307

Annually lahat except for skeletal (1-2 yrs)

Question 308

when does calcium go down after parathyroidectomy?

Answer 308

A decline in serum calcium occurs within 24 h after successful surgery;

usually, blood calcium falls to low-normal values for 3–5 days until the remaining parathyroid tissue resumes full hormone secretion

Question 309

What level of Calcium do you usually expect Chovstek’s and Trosseaus

Answer 309

Signs of hypocalcemia include symptoms such as muscle twitching, a general sense of anxiety, and positive Chvostek’s and Trousseau’s signs coupled with serum calcium consistently <2 mmol/L (8 mg/dL)

Question 310

What is the recommended rate of infusion when correcting for hypocalcemia?

Answer 310

An infusion of 0.5–2 mg/kg per hour or 30–100 mL/h of a 1-mg/mL solution usually suffices to relieve symptoms.

Usually, parenteral therapy is required for only a few days. If symptoms worsen or if parenteral calcium is needed for >2–3 days, therapy with a vitamin D analogue and/or oral calcium (2–4 g/d) should be started. It is cost-effective to use calcitriol (doses of 0.5–1 μg/d) because of the rapidity of onset of effect and prompt cessation of action when stopped, in comparison to other forms of vitamin D

Question 311

What is the effect of magnesium on PTH?

Answer 311

If magnesium deficiency is present, it can complicate the postoperative course since magnesium deficiency impairs the secretion of PTH

Question 312

responsible humoral agent in most solid tumors that cause hypercalcemia

Answer 312

PTHrP

Question 313

histolgy of solid tumor associated with hypercalcemia

Answer 313

Squamous cell tumors are most frequently associated with hypercalcemia, particularly tumors of the lung, kidney, head and neck, and urogenital tract.

Question 314

___- dependent reduction in 1,25(OH)2 D thus seems to be an important stimulus for the development of secondary hyperparathyroidism

Answer 314

FGF23

Question 315

The bone disease seen in patients with secondary hyperparathyroidism and CKD is termed ____ and affects primarily bone turnover

Answer 315

renal osteodystrophy

Question 316

How is hypocalcemia due to secondary hyperparathyroidism treated?

Answer 316

> includes reduction of excessive blood phosphate by restriction of dietary phosphate, the use of nonabsorbable phosphate binders, and careful, selective addition of calcitriol (0.25–2 μg/d) or related analogues.

> Calcium carbonate became preferred over aluminumcontaining antacids to prevent aluminum-induced bone disease. However, synthetic gels that also bind phosphate (such as sevelamer) are now widely used, with the advantage of avoiding not only aluminum retention but also excess calcium loading, which may contribute to cardiovascular calcifications.

> Intravenous calcitriol (or related analogues), administered as several pulses each week, helps control secondary hyperparathyroidism.

Question 317

Most common form of hyperparathyroidism

Answer 317

Asymptomatic

Question 318

Lab test that may help differentiate hyperpathyroidism with other causes of hypercalcemia

Answer 318

The immunoassay for PTH usually separates hyperparathyroidism from all other causes of hypercalcemia (exceptions are very rare reports of ectopic production of excess PTH by nonparathyroid tumors).

Patients with hyperparathyroidism have elevated PTH levels despite hypercalcemia, whereas patients with malignancy and the other causes of hypercalcemia (except for disorders mediated by PTH such as lithium-induced hypercalcemia) have levels of hormone below normal or undetectable

Question 319

How can 1,25(OH)2 D levels differetiate primary hyperparathyroidism from other disorders associated with hypercalcemia?

Answer 319

1,25(OH)2 D levels are elevated in many (but not all) patients with primary hyperparathyroidism. In other disorders associated with hypercalcemia, concentrations of 1,25(OH)2 D are low or, at the most, normal

Measurement of 1,25(OH)2 D is critically valuable in establishing the cause of hypercalcemia in sarcoidosis and certain lymphomas.

Question 320

What tx option for severe hypercalcemia may present with fever?

Answer 320

Pamidronate

Question 321

What tx option for severe hypercalcemia has the highest antiresorptive properties?

Answer 321

Denosumab

Question 322

What tx option for severe hypercalcemia is associated with tachyphylaxis?

Answer 322

Calcitonin

Question 323

a monoclonal antibody that binds to RANK ligand (RANKL) and prevents it from binding to the receptor RANK on osteoclast precursors and mature osteoclasts.

Answer 323

Denosumab

Question 324

Duration of effec of calcitonin

Answer 324

Calcitonin, after 24 h of use, is no longer effective in lowering calcium

Question 325

The malignancies in which hypercalcemia responds to glucocorticoids include

Answer 325

multiple myeloma, leukemia, Hodgkin’s disease, other lymphomas, and carcinoma of the breast, at least early in the course of the diseases

Question 325

Approach to management of severe hypercalcemia

Answer 325

Severe hypercalcemia (≥3.7 mmol/L [15 mg/dL]) requires rapid correction. IV pamidronate or zoledronate or subcutaneous denosumab should be administered.

In addition, for the first 24–48 h, aggressive sodium-calcium diuresis with IV saline should be given and, following rehydration, large doses of furosemide or ethacrynic acid, but only if appropriate monitoring is available and cardiac and renal function are adequate

Question 326

Definition of osteoporosis

Answer 326

2.5 standard deviations (SDs) or more below the mean for young healthy adults of the same sex and race—also referred to as a T-score of –2.5.

Patients who present with hip or spine fractures by definition have osteoporosis and will require treatment for both the fractureitself and the underlying skeletal disorder

Question 327

How does vitamin d insufficiency cause osteoporosis?

Answer 327

Vitamin D insufficiency leads to compensatory secondary hyperparathyroidism and is an important risk factor for osteoporosis and fractures

Question 328

How does estrogen deficiency cause bone loss?

Answer 328

Estrogen deficiency causes bone loss by two distinct but interrelated mechanisms: (1) activation of new bone remodeling sites and (2) initiation or exaggeration of an imbalance between bone formation and resorption, in favor of the latter

Loss of estrogen increases production of RANKL and reduces production of osteoprotegerin, increasing osteoclast formation and recruitment

Question 329

What are the drugs associated with osteoporosis?

Answer 329

See table

Glucocorticoids are the most common cause of medication-induced osteoporosis

Question 330

What are the indications for BMD testing?

Answer 330

Question 331

Indications for vertebral testing

Answer 331

Question 332

When osteoporosis is found associated with symptoms of rash, multiple allergies, diarrhea, or flushing, mastocytosis should be considered and excluded by using ______

Answer 332

24-h urine histamine collection or serum tryptase

Question 332

Biochemical markers of bone metabolism

Answer 332

Question 333

Adequate calcium intake per age group

Answer 333

Question 334

SERM that protects the uterus and breast from effects of estrogen and makes the use of progestin unnecessary

Answer 334

Bazedoxifene

Question 335

Tamoxifen is protective against breast CA but increases the risk for this type of CA

Answer 335

uterine

unlike raloxifene

Question 336

Contraindication of alendronate

Answer 336

contraindicated in patients who have stricture or inadequate emptying of the esophagus

Question 337

Adverse events associated with bisphosphonate

Answer 337

All bisphosphonates have been associated with some musculoskeletal and joint pains of unclear etiology, which are occasionally severe. There is potential for renal toxicity, and bisphosphonates are contraindicated in those with an estimated glomerular filtration rate <30–35 mL/min. Hypocalcemia can occur.

Also associated with osteonecrosis of the jaw and atypical femoral fracture

Question 338

What treatment for osteoporosis when discontinued is associated with rebound increase in bone turnover and bone loss

Answer 338

When denosumab is discontinued, there is a rebound increase in bone turnover and an apparent acceleration of bone loss. This likely reflects the maturation of osteoclast precursors that have accumulated in marrow when the drug was administered and can become mature bone resorbing cells once the drug is withdrawn

Question 339

a humanized antibody that blocks the osteocyte production of sclerostin, resulting in an increase in bone formation and decline in bone resorption

Answer 339

romosozumab

Question 340

a cathepsin K inhibitor, inhibits the osteoclast collagenase enzyme, preventing bone resorption but not affecting osteoclast viability

Answer 340

odanacatib

Question 341

Currently ______ measured on a fasting serum sample in the morning is the preferred marker of bone resorption, and ____ or ____ the is the preferred marker for formation

Answer 341

collagen C-telopeptide

osteocalcin or propeptide of type 1 collagen (P1NP)

Question 342

All patients on long-term (>___ months) glucocorticoids should have measurement of bone mass at both the spine and the hip using DXA

Answer 342

3

If only one skeletal site can be measured, it is best to assess the spine in individuals <60 years and the hip in those >60 years.

Question 343

Which of the following is more characteristic of
an ACTH-secreting pituitary tumor as compared to an ectopic ACTH secretion?
A. Rapid in onset
B. More common in males than females
C. Serum potassium is < 3.3 ug/L in less than 10 percent of cases
D. Cortisol > 5ug/dL after high dose dexamethasone suppression testing

Answer 343

C. Serum potassium is < 3.3 ug/L in less than 10 percent of cases

Question 344

Which of the following organisms cause chronic thyroiditis?
A. Aspergillus
B. Mycobacteria
C. Strongyloides
D. Viral

Answer 344

C. Strongyloides

Question 345

What is the putative trigger to develop Type 1 DM in genetically susceptible individuals?
A. Coxsackie virus
B. Parvovirus
C. HIV
D. HPV

Answer 345

A. Coxsackie virus

Question 346

45. A 35/M was previously diagnosed by his primary care physician with diabetes 5 years ago. He was initially started on insulin but was eventually shifted to metformin once his sugar was controlled. On physical exam, his BMI is 20 kg/m2 and does not exhibit acanthosis nigricans. He, however, complains of alopecia. CBG taken was 350 mg/dl but stat ketones were negative. On work-up, islet antibodies were positive. What is the most likely diagnosis for this patient?
    A. Ketosis-prone type 2 diabetes mellitus
    B. Latent autoimmune diabetes of the adult
    C. Maturity-onset diabetes of the young
    D. Fulminant diabetes

Answer 346

B. Latent autoimmune diabetes of the adult

Question 347

A 38/F came into your clinic concerned about having diabetes. She has a strong family history of the disease and her father progressed to dialysis-requiring renal failure because of it. Her BMI is 28 kg/m2. She was otherwise asymptomatic and physical examination was unremarkable. When is it appropriate to screen diabetes and repeat the test if results are normal?
A. Now then every year thereafter
B. Now then every three years
C. Age 40 then every year thereafter
D. Age 40 then every three years

Answer 347

A. Now then every year thereafter

Question 348

What lipid lowering drug has been shown to reduce the progression of retinopathy without reducing cardiovascular events?
A. Statins
B. Fenofibrate
C. Niacin
D. Bile acid resin

Answer 348

B. Fenofibrate

Question 349

The body’s behavioral defense against hypoglycemia is effective at what glycemic threshold?
A. 80-85 mg/dL
B. 65-70 mg/dL
C. 50-55 mg/dL
D. <50 mg/dL

Answer 349

C. 50-55 mg/dL

Question 350

Which of the following patients with subclinical hypothyroidism will benefit from levothyroxine?
A. 45 year old woman with palpitations
B. 50 year old man, asymptomatic, TSH of 15 mIU/L
C. 55 year old perimenopausal woman
D. 60 year old man, admitted for pneumonia

Answer 350

B. 50 year old man, asymptomatic, TSH of 15 mIU/L

since TSH >10

Question 351

A 19-year-old college student comes to the clinic reporting infrequent palpitations. He reports no other symptoms. He had thyroid tests done revealing the following: TSH 0.35 Uiu/ml (N 0.4-6.0), FT4 1.5 ng/dL (N 0.8-2.0), FT3 5.6 pmol/L (N 4.0-7.4). PE, including neck exam, is unremarkable. What is the diagnosis?
A. Primary thyrotoxicosis
B. Subacute thyroiditis
C. Subclinical hyperthyroidism
D. Subclinical hypothyroidism

Answer 351

C. Subclinical hyperthyroidism

Question 352

A 22-year-old woman presents with tremors, palpitations, diffusely enlarged thyroid gland and characteristic eye stare. Tests show low TSH and elevated FT3 and FT4. She is started on once-daily methimazole. 2 weeks later, she calls you to report fever and a sore throat. What will be your advice?
A. Discontinue the drug and have a CBC done
B. Hold the drug until the fever subsides
C. Substitute the methimazole with propylthiouracil
D. Take paracetamol and reassure the patient

Answer 352

A. Discontinue the drug and have a CBC done

Question 353

A 33-year-old consults in the clinic for a palpable thyroid nodule. She denies any hypo-/ hyperthyroid symptoms. On ultrasound, the nodule appears fluid-filled, with smooth, sharp borders. What is the most likely diagnosis?
A. Classic papillary carcinoma
B. Colloid nodule
C. Hurthle cell adenoma
D. Thyroid metastasis

Answer 353

B. Colloid nodule

Question 354

A 42-year-old comes in for a follow-up visit. She has been diagnosed with papillary thyroid cancer, initially presenting with a palpable thyroid nodule. She has undergone total thyroidectomy, with a tumor size of 1.5 cm. There are no signs of regional and distal metastases. What is the next step in this patient’s management?
A. Field radiation therapy
B. Multi-drug chemotherapy
C. Radioiodine treatment
D. TSH suppression therapy

Answer 354

D. TSH suppression therapy

Question 355

A 30-year-old woman came in due to 5 year history of gradually enlarging anterior neck mass. Biopsy reveals papillary thyroid carcinoma. A total thyroidectomy is done but there is residual thyroid tissue due to the encasement of internal carotid area. What will be the TSH goal of this patient?
A. <0.1 mIU/L
B. 0.1-0.5 mIU/L
C. 0.5-1 mIU/L
D. 0.5-2 mIU/L

Answer 355

A. <0.1 mIU/L

Question 356

Which of the following is characteristic of primary adrenal insufficiency?
A. High ACTH, high renin, low aldosterone
B. High ACTH, low renin, high aldosterone
C. Low ACTH, high renin, low aldosterone
D. Low ACTH, low renin, high aldosterone

Answer 356

A. High ACTH, high renin, low aldosterone

Question 357

A 46-year-old man is referred to you for a consideration of pheochromocytoma, after presenting with headaches, palpitations and anxiety. Except for hypertension, his medical history is unremarkable. Medications are lisinopril and amlodipine. On PE, BP is 170/90 mmHg, and HR is 90/min. The remainder of the PE is unrevealing. Plasma free metanephrines are 3.5x elevated. What is the most appropriate next step in the management?
A. Discontinue antihypertensives and repeat biochemical testing
B. Perform clonidine suppression test
C. Perform contrast-enhanced adrenal CT scan
D. Start propranolol for additional BP control and relief of palpitations

Answer 357

C. Perform contrast-enhanced adrenal CT scan

Question 358

Aside from symptomatic relief of menopause, which of the following is a definite benefit from the use of postmenopausal hormonal therapy?
A. Decrease in risk of dementia in older women
B. Decrease in risk of endometrial cancer
C. Increase in bone mineral density
D. Increase in risk of gallbladder disease

Answer 358

C. Increase in bone mineral density

Question 359

A 58-year old consults for vaginal dryness, hot flashes and sleep disturbances. She is menopause since 3 years prior. Medical history is pertinent for controlled type 2 diabetes diagnosed 7 years prior, diabetic kidney disease (eGFR 56 mL/min/1.73m2 ), non-alcoholic fatty liver disease (NAFLD), glaucoma and depressive disorder. Medications include once-daily metformin, silymarin, fluoxetine and timolol eyedrops. She asks about hormonal therapy, but is wary due to her multiple co-morbid illnesses. Which of the following is a contraindication in this patient’s case?
A. Concomitant antidepressant use
B. History of glaucoma
C. Liver disease
D. Low eGFR

Answer 359

C. Liver disease

Others: unexplained vaginal bleeding, VTE, thrombophilia

Question 360

A 45-year-old woman is referred to you for “abnormal FBS.” She has no known co-morbidities, and a routine fasting sugar is 122 mg/dL. BMI is 36. Which of the following medications will offer the greatest weight loss? A. Insulin
B. Metformin
C. Orlistat
D. Pioglitazone

Answer 360

C. Orlistat

Weight loss 9-10%/yr

Question 361

Patients with dka would present with high or low triglycerides?

Answer 361

high

Question 362

Which of the following risk factors has the highest relative risk for the occurrence of diabetes mellitus (DM)? (UNITE CPG)
A. Conditions associated with insulin resistance (e.g. acanthosis nigricans)
B. Previous history of gestational DM
C. Previous history of increased fasting glucose (IFG)
D. Previous history of impaired glucose tolerance (IGT)

Answer 362

C. Previous history of increased fasting glucose (IFG)

Question 363

medications approved for use in the management of chronic painful diabetic neuropathy

Answer 363

Duloxetine and Pregabalin

Question 364

Which of the following fulfills criteria for metabolic syndrome according to the Harmonizing Definition Criteria?
A. Filipino female, with BP of 130/80 mmHg
B. Filipino female, with HDL of 45 mg/dL
C. Filipino male, with waist circumference of 84 cm
D. Filipino male, with fasting blood sugar of 92 mg/dL

Answer 364

B. Filipino female, with HDL of 45 mg/dL

Question 365

Definition of osteopenia

Answer 365

-1 to -2.5

Question 366

In which of the following situations will you recommend bone mineral density testing?
A. 20-year old man, smoker, with family history of fragility fracture
B. 30-year old woman with lupus, on prednisone 10mg/day for the last 6 months
C. 50-year old man with back pain and a lumbosacral x-ray showing bone spurs
D. 60-year old woman, formerly a marathon runner

Answer 366

B. 30-year old woman with lupus, on prednisone 10mg/day for the last 6 months

prednisone >5 mg/day for >3 mos

Question 367

During pregnancy, propylthiouracil should be limited to the first trimester. Subsequently, maternal anti-thyroid therapy should be converted to methimazole at a ratio of:
a. 5-10 mg of propylthiouracil to 1 mg of methimazole
b. 15–20 mg of propylthiouracil to 1 mg of methimazole
c. 25-30 mg of propylthiouracil to 1 mg of methimazole
d. 30-40 mg of propylthiouracil to 1 mg of methimazole

Answer 367

b. 15–20 mg of propylthiouracil to 1 mg of methimazole