Professional Documents
Culture Documents
html
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/1.html28/03/2006 06:39:49 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/2.html
A 18-year-old woman is brought to the clinic by her parents, who report that
she has been increasingly weak and fatigued for the past 6 months. She has
no prior medical history and denies any medication use. On physical
examination, she has a blood pressure of 85/60 mm Hg and is tachycardic
with a pulse of 110/min. Laboratory studies are notable for a normal sodium,
potassium of 2.2 mEq/L, and a plasma bicarbonate of 44 mEq/L. Which of
the following is the most likely cause of her hypokalemic alkalosis?
A. Chronic diarrhea
B. Cushing syndrome
C. Licorice ingestion
D. Primary aldosteronism
E. Surreptitious vomiting
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/2.html28/03/2006 06:39:50 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/3.html
A. Captopril
B. Furosemide
C. Hydrochlorothiazide
D. Propanolol
E. Spironolactone
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/3.html28/03/2006 06:39:50 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/4.html
Sodium.............139 mEq/L
Potassium........4.5 mEq/L
Bicarbonate.....23 mEq/L
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/4.html28/03/2006 06:39:51 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/5.html
One month following delivery of her baby, a new mother complains to her
physician of feeling very tired and cold all of the time, even when she gets
adequate sleep. Physical examination is notable for marginal thyroid
enlargement without tenderness. Thyroid studies show a total T4 of 3.5 •g/
dL, with third-generation studies showing a thyroid-stimulating hormone
(TSH) of 7.5 •U/mL. Which of the following is the most likely diagnosis?
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/5.html28/03/2006 06:39:51 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/6.html
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/6.html28/03/2006 06:39:52 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/7.html
A. 6 mEq/L
B. 11 mEq/L
C. 13 mEq/L
D. 15 mEq/L
E. 20 mEq/L
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/7.html28/03/2006 06:39:52 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/8.html
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/8.html28/03/2006 06:39:52 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/9.html
A. Postpartum depression
B. Primary adrenal insufficiency
C. Primary hypothyroidism
D. Sheehan syndrome
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...20bank%20new!!!%20PART03/Medicine%202/endo%2021/9.html28/03/2006 06:39:53 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/10.html
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/10.html28/03/2006 06:39:53 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/11.html
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/11.html28/03/2006 06:39:54 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/12.html
Sodium........................130 mEq/L
Potassium...................6.5 mEq/L
Bicarbonate................20 mEq/L
Leukocyte count..............5000/mm3
Segmented neutrophils......40%
Lymphocytes...................40%
Monocytes .....................6%
Eosinophils......................9.5%
Basophils........................0.5%
A. Addison's disease
B. Conn's syndrome
C. Cushing's disease
D. Cushing's syndrome
E. Syndrome of inappropriate antidiuretic hormone secretion
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/12.html28/03/2006 06:39:54 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/13.html
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/13.html28/03/2006 06:39:55 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/14.html
A. Bisphosphonates
B. Calcitonin
C. Calcium and vitamin D
D. Conjugated estrogens
E. Sodium fluoride
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/14.html28/03/2006 06:39:55 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/15.html
A. Angiokeratomas
B. Grey-brown pigmentation of the forehead, hands, and pre-tibial
region
C. Irregular black deposits of clumped pigment in the peripheral retina
D. Orange-yellow tonsillar hyperplasia
E. Pingueculae
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/15.html28/03/2006 06:39:55 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/16.html
A. Calcitonin
B. Etidronate
C. Hydrochlorothiazide
D. IV saline
E. Prednisone
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/16.html28/03/2006 06:39:56 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/17.html
A. Graves disease
B. Hashimoto thyroiditis
C. Postpartum thyroiditis
D. Riedel thyroiditis
E. Sheehan syndrome
F. Subacute (de Quervain) thyroiditis
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/17.html28/03/2006 06:39:56 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/18.html
A. Colon
B. Lung
C. Pancreas
D. Stomach
E. Testis
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/18.html28/03/2006 06:39:57 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/19.html
A. Cholestasis
B. Granulocytopenia
C. Hypothyroidism
D. Recurrent laryngeal nerve damage
E. Thyroid carcinoma
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/19.html28/03/2006 06:39:57 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/20.html
A 35-year-old male has been complaining of headaches for the past 6 months
and has been reporting changes in his vision. On examination he has loss of
visual fields bilaterally and gets a magnetic resonance image (MRI) of his
brain. This shows a pituitary adenoma. Which of the following hormones is
most likely to be elevated in this patient?
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/20.html28/03/2006 06:39:58 •
file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...ep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/21.html
A. IV hypertonic saline
B. IV pressor support
C. IV thyroxine
D. Endotracheal intubation and mechanical ventilation
E. Cardiac defibrillation
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...0bank%20new!!!%20PART03/Medicine%202/endo%2021/21.html28/03/2006 06:39:59 •
Explanation
Explanation - Q: 1 Close
The correct answer is C. MRI with gadolinium is considered the most sensitive test for detecting
microadenoma. The test can reveal microadenomas in 20% of normal women.
CT scans can be quite sensitive in the detection of microadenomas, but MRIs are even more so
(choice A).
The serum prolactin level is elevated due to hypersecretion in 30-50% of patients (choice D).
For the optic chiasm to be compressed in order to cause visual field changes, the microadenoma
would have to be quite large, and a screening test based on this finding would be ineffective
(choice E).
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/1ans.html28/03/2006 06:40:37 •
Explanation
Explanation - Q: 2 Close
The correct answer is E. Hypokalemia can occur in each of the above conditions. The
combination of alkalosis and hypokalemia suggests surreptitious vomiting. By vomiting, the
patient loses protons in the form of acid in the stomach, effectively making her alkalotic. To
correct for the alkalosis, the proton-potassium antiport system pumps out protons and increases
the intracellular concentration of potassium, thus decreasing the serum potassium level. The
patient is hypotensive from the fluid loss.
Chronic diarrhea (choice A) is characterized by acidosis, rather than alkalosis, since basic salts are
lost through the lower gastrointestinal system. Potassium is still lost, and the patient will be
hypokalemic. Given the fluid loss, she would be hypotensive as well.
Primary aldosteronism (choice D) can be the result of an adrenal adenoma that produces excessive
amounts of aldosterone. The aldosterone increases the reabsorption of sodium and the excretion of
potassium and hydrogen ions in the distal renal tubules, producing hypokalemia, alkalosis, and
hypertension. The sodium retention leads to increased intravascular volume.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/2ans.html28/03/2006 06:40:38 •
Explanation
Explanation - Q: 3 Close
The correct answer is E. Hypertension with an adrenal mass should bring to mind two distinct
conditions: an epinephrine/norepinephrine-secreting pheochromocytoma, or an aldosterone-
secreting adrenocortical tumor (which can produce Conn syndrome). Although both of these can
produce hypertension, other aspects of the clinical presentation are quite different.
Pheochromocytoma can produce either episodic severe hypertension or continuous hypertension.
In either situation, electrolyte studies are usually normal. In contrast, Conn syndrome (which this
patient has) often shows prominent symptoms related to hypokalemia, including weakness,
paresthesias, and transient paralysis. The treatment of hypertension related to high aldosterone
levels is to block the aldosterone activity with the potassium-sparing diuretic (and anti-aldosterone
agent) spironolactone.
Captopril (choice A) is an angiotensin converting enzyme (ACE) inhibitor that works well to
reduce blood pressure in many patients by blocking the renin-angiotensin system; however, it is
less effective when there is already an excess of aldosterone present.
Furosemide (choice B), a loop diuretic, and hydrochlorothiazide (choice C), a thiazide type
diuretic, would tend to make the patient's hypokalemia worse.
Propanolol (choice D) is a beta blocker that would reduce blood pressure but would not
specifically counter the cause of this patient's hypertension.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/3ans.html28/03/2006 06:40:39 •
Explanation
Explanation - Q: 4 Close
Decreased excretion of uric acid (choice A) is the most common cause of hyperuricemia and gout.
It can be caused by increased tubular absorption, decreased tubular secretion, or decreased
glomerular filtration. These individuals typically have a uric acid level greater than 7 mg/dL.
Complications include gouty arthritis, nephrolithiasis, renal insufficiency, and renal failure.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/4ans.html28/03/2006 06:40:39 •
Explanation
Explanation - Q: 5 Close
Euthyroid sick syndrome (choice A) is typically seen in intensive care patients who do not have
true clinical hypothyroidism.
Iodine deficiency (choice C) is now a rare cause of goiter and hypothyroidism in the U.S.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/5ans.html28/03/2006 06:40:39 •
Explanation
Explanation - Q: 6 Close
The correct answer is C. In the presence of hypertension of recent onset, along with dermal
striae, easy bruisability, and evidence of glucose intolerance (glycosuria), hypercortisolism should
be suspected. The first test to perform is the dexamethasone suppression, which consists of
administering 1 mg of dexamethasone at 11 PM, and then measuring serum cortisol levels in a
blood sample drawn at 8 AM next day. Abnormally high cortisol levels after this test confirms
hypercortisolism. The next step is to find the source of excessive cortisol or ACTH. Other
manifestations of hypercortisolism include osteoporosis, muscle wasting, psychologic alterations,
hirsutism, and granulocytic leukocytosis with lymphopenia.
CT scans of the chest and abdomen (choice B) are performed to look for ectopic sources of
ACTH. These radiologic studies are especially useful in finding neoplasms that may manifest with
inappropriate ACTH secretion, the most frequent of which being small cell carcinoma of the lungs.
Measurement of midnight serum cortisol level (choice D) helps distinguish Cushing syndrome
from other causes of pseudo-Cushing states, such as alcoholism, depression, and anorexia
nervosa. This test requires the patient to remain in the same time zone for 3 consecutive days, be
without food for at least 3 hours, and have an indwelling catheter ready for the blood draw.
Measurement of 24-hour urine cortisol and creatinine (choice E) may become necessary for some
patients in whom the dexamethasone suppression test gives equivocal results. The above
mentioned pseudo-Cushing states, however, may show abnormally high levels of free urine
cortisol.
MRI of the head (choice F) is the method of choice to study the pituitary gland and look for
adenomas. ACTH-producing adenoma is the cause of Cushing disease, which accounts for 70% of
cases of hypercortisolism not due to exogenous corticosteroids.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/6ans.html28/03/2006 06:40:39 •
Explanation
Explanation - Q: 7 Close
The correct answer is E. The patient is in diabetic ketoacidosis, as indicated by the acetone scent
to the breath and the glucose and ketones in the urine. Diabetic ketoacidosis produces an increased
anion gap, since the anion for the acid that is produced (acetoacetate) is not one of the usually
measured ions. The anion gap is usually estimated by subtracting the sum of the Cl- and HCO3-
concentrations from the plasma Na+ concentration; the normal value for the anion gap is 12 ± 4
mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes
mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or
metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of
protein anions, and dehydration (hemoconcentration).
6 mEq/L (choice A) is below the lower limit of normal. The anion gap may be decreased because
of a decrease of negatively charged serum proteins (eg, in hypoalbuminemia), an increase in
proteins carrying few negative charges (eg, hypergammaglobulinemia), or an increase in
unmeasured cations (e.g., magnesium, calcium, or lithium).
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/7ans.html28/03/2006 06:40:40 •
Explanation
Explanation - Q: 8 Close
The correct answer is C. The patient initially had osteitis fibrosa cystica as a result of the
primary hyperparathyroidism. When the adenoma was removed and PTH level decreased, the
skeleton underwent rapid remineralization. This created an increase in calcium requirement. Once
the repair was complete, the calcium demand decreased.
If the remaining glands were destroyed (choice A) she would have been permanently
hypocalcemic.
Severe pancreatitis would cause saponification and hypocalcemia (choice D). She would also
have symptoms of epigastric pain.
If the wrong gland were removed, she would be still hypercalcemic (choice E).
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/8ans.html28/03/2006 06:40:40 •
Explanation
Explanation - Q: 9 Close
Primary adrenal insufficiency (choice B) would explain only part of the syndrome in this case,
such as fatigue and hypotension, but not amenorrhea, cold intolerance, and skin changes. In
addition, primary hypocortisolism (i.e., due to destruction of adrenal glands) would be associated
with skin hyperpigmentation.
Primary hypothyroidism (choice C) may produce a similar clinical picture, but the history of
difficult parturition with abundant blood loss and the wide-ranging symptomatology suggesting
multiple endocrine deficits make panhypopituitarism more likely.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...ank%20new!!!%20PART03/Medicine%202/endo%2021/9ans.html28/03/2006 06:40:40 •
Explanation
Explanation - Q: 10 Close
The correct answer is A. While there is some variation in the usage of the term, Addison disease
is usually taken to mean adrenocortical insufficiency related to disease that destroys the adrenal
gland. Most authors separate out secondary adrenocortical insufficiency due to pituitary failure
and recent or current exogenous steroid therapy. True Addison disease, which is not related to
inadequate pituitary secretion of ACTH, frequently has stigmata of hyperpigmentation relating to
a melanocyte-stimulating hormone (MSH) effect seen with high ACTH levels. The biochemical
basis of this is a homology between part of the ACTH molecule and the MSH molecule. Typical
hyperpigmentation features include black freckles of the shoulders, head, and neck; bluish-black
discoloration of areolas and mucous membranes (both oral and anogenital); and diffuse tanning,
specifically including non-sun-exposed skin. The pattern of laboratory screening studies
illustrated in the question stem is also very suggestive, with very low serum sodium, high
potassium, low bicarbonate, and high serum urea nitrogen.
Small glistening bumps on the lips (choice E) suggests the mucosal neuromas of MEN IIb.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/10ans.html28/03/2006 06:40:40 •
Explanation
Explanation - Q: 11 Close
The correct answer is A. This patient has central diabetes insipidus. People can slowly develop
dietary or drinking habits that seem perfectly normal to them, but appear strikingly unusual to
other people. This frequently happens with conditions related to fluid balance, and the patient may
be coping with a significant underlying problem without even realizing it. It may only be when
something unusual happens, such as this woman's car trip, that the patient comes to medical
attention. In this case, the patient essentially underwent a water deprivation test, but without the
close medical supervision always offered when such a test is performed in a hospital setting. The
facts that she continued to produce dilute urine and that the urine osmolarity could be increased
with vasopressin indicate that the diabetes insipidus probably has a central origin. A head CT
would likely confirm the diagnosis by showing a large pituitary adenoma, which could
compromise antidiuretic hormone flow down the pituitary stalk.
Compulsive water drinking (choice B) is more likely to mimic nephrogenic diabetes insipidus
than central diabetes insipidus.
Diabetes mellitus (choices C and D) can produce high urine flow rates, but only secondary to an
osmotic diuresis seen when urine glucose is high.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/11ans.html28/03/2006 06:40:40 •
Explanation
Explanation - Q: 12 Close
The correct answer is A. This patient most likely has Addison's disease, which is primary
adrenocortical deficiency. It is a rare disease that is caused by a progressive destruction of the
adrenal glands, usually due to idiopathic atrophy, surgery, infection, or hemorrhage. The clinical
symptoms include weakness, weight loss, hyperpigmentation, nausea and vomiting, and
hypotension. Laboratory findings include hyponatremia (due to aldosterone deficiency),
hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is
made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the
ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.
Cushing's syndrome (choice D) is similar to Cushing's disease except that it is due to adrenal
hyperplasia, an adrenal neoplasm or exogenous, iatrogenic causes.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/12ans.html28/03/2006 06:40:41 •
Explanation
Explanation - Q: 13 Close
The correct answer is A. This patient is seriously ill, with low T4 and low T3, but normal TSH.
This is typical for euthyroid sick syndrome, which occurs in many seriously ill patients who do
not have clinical hypothyroidism. It can be enough of a diagnostic problem that some references
suggest that thyroid hormones not be measured in patients in the intensive care unit unless they
are strongly clinically suspected of having thyroid disease. The TSH level is usually most helpful
in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL
in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick
syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4
may be normal or decreased.
Medullary carcinoma of the thyroid (choice D) is rare and would probably not affect the serum
thyroid hormone levels unless it was very extensive.
Silent lymphocytic thyroiditis (choice E) can cause hypothyroidism that typically occurs in the
postpartum period.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/13ans.html28/03/2006 06:40:41 •
Explanation
Explanation - Q: 14 Close
The correct answer is D. Early intervention can prevent osteoporosis. Later intervention can halt
its progression, but it is not currently possible to reverse established disease. All current therapies
for osteoporosis are directed at inhibiting bone resorption. Bone loss is greatest within the first
year of menopause so these agents are likely to be most efficacious if started at this time. Estrogen
reduces the rate of bone loss and improves density. The beneficial effects of estrogen replacement
are well-documented, and it is estimated that less than 20% of women are taking estrogens,
despite their enormous benefit. Additionally, estrogen replacement has been shown to be
important for prevention of coronary disease in this age group.
Bisphosphonates (choice A) are agents that inhibit osteoclastic bone resorption. These agents are
efficacious for both prevention and treatment of disease. In some trials, their effect on augmenting
bone density is similar to that of estrogens. However, given the side effects of these agents
(esophagitis) as well as the other beneficial effects of estrogens (effects on HDL, LDL and
coronary disease), estrogen is still the agent of choice for prevention.
Calcitonin (choice B) is FDA-approved only for established disease, but studies have shown
conflicting results regarding its efficacy.
Calcium and vitamin D (choice C) are critical components of prevention and ongoing treatment,
but the effects of giving calcium and vitamin D supplements are proportional to the duration of
therapy. Most postmenopausal women receive less than the recommended calcium intake (1500
mg/day) and have hypovitaminosis D (<15 ng/mL 25-hydroxy vitamin D levels). Calcium and
vitamin D is the cornerstone of good therapy whether hormone replacement is utilized or not, but
the effects are generally not significant unless begun early in life.
Sodium fluoride (choice E) has been supplanted by newer therapies and is used primarily in
Europe for treatment of established disease.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/14ans.html28/03/2006 06:40:41 •
Explanation
Explanation - Q: 15 Close
The correct answer is D. Tangier disease is a rare familial disorder characterized by alpha-
lipoprotein deficiency, which leads to very low high-density lipoprotein (HDL), recurrent
polyneuropathy, lymphadenopathy, and hepatosplenomegaly due to storage of cholesterol esters
in reticuloendothelial cells. Although you may never see this disease, the association of orange-
yellow tonsillar hyperplasia (due to the cholesterol ester deposition there as well) with Tangier
disease is a sufficiently distinctive clue in physical diagnosis to be worth remembering. (One rule
of thumb in medicine is that although you will probably never see most of the very rare diseases,
you will almost certainly see some of them.)
The presence of multiple angiokeratomas (choice A) on the lower half of the body suggests Fabry
disease.
Grey-brown pigmentation of the forehead, hands, and pre-tibial region (choice B) suggests
Gaucher disease.
Irregular black deposits of clumped pigment in the peripheral retina (choice C) are characteristic
of retinitis pigmentosa, which may occur in association with abetalipoproteinemia and Refsum
disease.
Pingueculae (choice E) could suggest Gaucher disease, but this could also occur in normal adults.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/15ans.html28/03/2006 06:40:41 •
Explanation
Explanation - Q: 16 Close
The correct answer is D. Hypercalcemia can be treated with IV saline and furosemide. Fluid
replacement with IV saline and forced diuresis with saline and a loop diuretic, such as furosemide,
is a rapid and safe way to lower serum calcium and should be the initial approach to therapy. This
patient has lung cancer and is probably exhibiting a paraneoplastic secretion of parathyroid-related
hormone, which is making him hypercalcemic.
Calcitonin (choice A), a hormone secreted by the parafollicular cells of the thyroid, inhibits
osteoclast activity and decreases the rate of bone loss and fractures in osteoporosis. It may be
added after IV hydration and diuresis with furosemide.
Hydrochlorothiazide (choice C) is a thiazide diuretic that decreases urinary calcium excretion and
can cause hypercalcemia.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/16ans.html28/03/2006 06:40:41 •
Explanation
Explanation - Q: 17 Close
The correct answer is C. The clinical manifestations are consistent with hyperthyroidism.
Especially suggestive are heat intolerance and systolic hypertension with a low diastolic pressure.
Anxiety, hand tremor, and warm skin are additional characteristic symptoms. Postpartum
thyroiditis is a frequent, but usually self-limited, postpartum complication. It develops a few
weeks following delivery and appears to result from an autoimmune response. A minority of cases
are followed by hypothyroidism. The gland is not swollen or finely nodular as occurs in
Hashimoto thyroiditis (choice B), which is also due to autoantibodies against thyroid antigens.
Riedel thyroiditis (choice D), also known as chronic fibrous thyroiditis, is an uncommon form of
chronic thyroiditis leading to sclerosis of the thyroid gland and adjacent structures. It manifests in
middle-aged or elderly women with slowly developing hypothyroidism and is characterized by a
stony hard thyroid on palpation.
Sheehan syndrome (choice E) is a rare syndrome due to complete ischemic necrosis of the
anterior pituitary gland, secondary to hypotension during complicated deliveries. It manifests with
panhypopituitarism (including secondary hypothyroidism).
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/17ans.html28/03/2006 06:40:42 •
Explanation
Explanation - Q: 18 Close
The correct answer is B. Cushing syndrome is a cluster of clinical abnormalities seen in the
setting of chronic exposure to high cortisol levels. Truncal obesity, buffalo hump, increased
susceptibility to infection, hypertension, and glucose intolerance are common manifestations.
Cushing syndrome can be due to administration of exogenous corticosteroids, adrenal hyperplasia
or tumor, pituitary adenoma, or ectopic ACTH production by another malignancy. The later is
most commonly a small cell carcinoma of the lung. Lung cancers are also notorious for a wide
variety of other paraneoplastic syndromes, including hypercalcemia, hypophosphatemia,
somatostatinoma syndrome (with prominent GI complaints), syndrome of inappropriate
antidiuretic hormone secretion (SIADH), Eaton-Lambert syndrome, polymyositis, cerebellar
degeneration, peripheral neuropathy, osteoarthropathy, marantic endocarditis, migratory
thrombophlebitis, and disseminated intravascular coagulation.
Cancers of the colon (choice A) can cause GI symptoms and anemia related to blood loss, but are
not a prominent cause of endocrine-related paraneoplastic syndromes.
Islet cell cancers of the pancreas (choice C) can secrete clinically significant amounts of insulin,
gastrin, glucagon, and vasoactive intestinal peptide, but do not usually secrete ACTH or
corticosteroids.
Cancers of the stomach (choice D) can cause symptoms such as jaundice and ascites related to
direct extension into perigastric sites, but are not a source of endocrine-related paraneoplastic
syndromes.
While some testicular cancers (choice E) can secrete tiny amounts of hormones such as human
chorionic gonadotropin (hCG), clinically significant endocrine disease does not usually occur.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/18ans.html28/03/2006 06:40:42 •
Explanation
Explanation - Q: 19 Close
The correct answer is C. Hypothyroidism is the main complication of radioactive iodine therapy,
affecting up to 70% of patients in 10 years. Radioactive iodine therapy is a safe and effective
treatment for Graves' disease because it can provide the same ablative effects of surgery without
the surgical complications. There is no evidence that this treatment increases the risk for
carcinoma (choice E).
Cholestasis (choice A) and granulocytopenia (choice B) are side effects of long-term antithyroid
therapy (propylthiouracil).
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/19ans.html28/03/2006 06:40:42 •
Explanation
Explanation - Q: 20 Close
The correct answer is C. 50% of pituitary adenomas have been found to secrete prolactin. Levels
of this hormone must be measured in a patient suspected of having a pituitary tumor.
Acromegaly due to growth hormone excess is an infrequent complication as well (choice B).
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/20ans.html28/03/2006 06:40:42 •
Explanation
Explanation - Q: 21 Close
The correct answer is D. Although this patient is likely in myxedema coma, the basics of
medical management ALWAYS take precedence. Airway, breathing, and circulation evaluation
are a priority in this patient with a respiratory rate less than 10 and clearly abnormal oxygen
saturation of her blood. In this patient, securing an airway and then addressing her remaining
issues are of paramount importance.
IV hypertonic saline (choice A) would be incorrect, for two reasons. First, the ABCs of medical
management take priority. Second, although many severely hypothyroid patients are
hyponatremic, this has yet to be demonstrated in this patient.
In this setting, pressors (choice B) need to be given via central venous line, and this access has not
yet been established in this patient.
IV thyroxine (choice C) would be the appropriate treatment AFTER thyroid function tests were
verified and the patient was stabilized.
Cardiac defibrillation (choice E) is incorrect because it is not yet known whether this person is
experiencing a dysrhythmia that would respond to this intervention. The two most common types
of such rhythms seen in this type of emergency setting are ventricular fibrillation and ventricular
tachycardia.
- - -
file:///C|/Documents%20and%20Settings/Home/Desktop/Dow...nk%20new!!!%20PART03/Medicine%202/endo%2021/21ans.html28/03/2006 06:40:43 •