Endocrine Revision Dr Hend M Abdelhakam MCQ 1

Endocrine Revision Dr. Hend M. Abdelhakam

MCQ • 1 - Typical symptoms of hypoglycaemia in diabetic patients include all the following except: • • • A) feelings of tirdness and hunger B) tremor, palpitation and dizziness C)headache, impaired cognitive function and confusion D) nocturnal sweating, nightmares and weight loss. answer is d

MCQ • 2 -22 ys old female presented in ER by disturbed level of consciousness, • dehydrated, hypotensive, tachycardia with recurrent Vomiting & abdominal pain What is your probable diagnosis: • A) DKA. • B) Diabetic Nephropathy • C) Lactic Acidosis • D) Hypopituitarism • Answer is (a )

MCQ • 3 - Thyroid Storm means: • A) Life threating untreated hyperthyroidism • B) Life threating untreated hypothyroidism • C) Inflammatory process of thyroid gland • D) Anti-thyroid drug overdose • Answer is (a )

MCQ • 4 -All the following are cardiovascular manifestation of hypothyroidism except: • A) pericardial effusion • B) bradyarrythmia • C) Ischemic heart disease • D) Rheumatic heart disease • Answer is (d)

MCQ • 5 -Complication of thyroidectomy all the following except : • A) Hypercalcemia • B) Recurrent laryngeal nerve palsy • C) Hypothyroidism. • D) Airway obstruction. • Answer is (a)

MCQ • 6 -The following are manifestations of Cushing syndrome; except: • A- Muscle wasting • B- Moon face • C- Hypernatremia • D- Hypoglycemia • answer is d

MCQ • 7 - The best to differentiate between central and nephrogenic Diabetes Insipidus is: • A- Water deprivation test • B- Nicotine test • C- Vasopressin test • D- Intravenous hyperosmolar saline test • answer is c

MCQ • 8 - Criteria of pheochromocytoma includes the following • except : • A- Paroxysmal hypertension • B- Paroxysmal bradycardia • C- Paroxysmal headache • D- Paroxysmal sweating • Answer is b

MCQ • 9 - Manifestations of Addison syndrome includes the following except: • A- Hypotension • B- Hyperglycemia • C- Asthenia • D- Hyperpigmentation of skin and mucus membranes • Answer is b

MCQ • 10 - Assay of Insulin growth factor-1 (IGF-1) can be used for • diagnosis of: • A- Diabetes mellitus • B- Acromegaly • C- Hypothyroidism • D- Hypoglycemia • Answer is b

MCQ 11 Physiologically; thyroid hormones promote the following except: • A. Fetal brain maturation • B. Gut motility • C. Bone formation • D. Cardiac contractility • Answer c

MCQ • 12. The aim of thyroxine therapy is: • A. Keeping normal TSH level • B. Achieving clinical improvement • C. Both A and B • D. None of the above • answer is c

MCQ • 13. Regarding thyroxine therapy, all the followings are true except: • A. Should be given in the morning • B. Should be given directly after meal • C. Should be monitored after 2 -4 weeks • D. Calcium supplement should be added • Answer is b •

MCQ • 14 A middle-age Female complains with repeated bouts of abdominal pain, sever hypertension, sweating and pallor, the most probable diagnosis is: • A. Conn's syndrome. • B. Cushing's syndrome. • C. Pheochromocytoma. • D. Thyroid storm • answer is c

MCQ • 15 Congenital adrenal hyperplasia characterized by the following except: • A. Low glucocorticoid level. • B. High adrenal androgen level. • C. Low ACTH level. • D. Low mineralocorticoid level. • Answer is c

MCQ • 16 -Adrenal insufficiency may be caused by: • A. Auto-immunity. • B. Sudden withdrawal of exogenous steroid. • C. TB • D. All of the above • Answer is d

MCQ • 17 -After dexamethasone administration; suppression of ACTH release suggests: • A. Adrenal cause of Cushing's. • B. Pituitary cause of Cushing's. • C. Ectopic cause of Cushing's. • D. None of the above • Answer is b

MCQ • 18 -Which of the following findings is most likely in a patient who has myxedema? • A) Somnolence • B) Palpitations • C) Increased respiratory rate • D) Increased cardiac output • E) Weight loss • Answer : A)

• 19 -. Which of the following hormones is both synthesized and stored in the pituitary gland? • A) Growth hormone (GH) • B) GH releasing hormone (GHRH) • C) ADH • D) Somatostatin • E) Somatomedin • Answer : A)

MCQ • 20 -Some cells secrete chemicals into the extracellular fluid that act on cells in the same tissue. Which of the following refers to this type of regulation? • A) Neural • B) Endocrine • C) Neuroendocrine • D) Paracrine • E) Autocrine • Answer : D)

MCQ • . 21 - Which of the following is inconsistent with the diagnosis of Graves’ disease? • A) Increased heart rate • B) Exophthalmos • C) Increased plasma levels of triiodothyronine (T 3) • D) Increased plasma levels of thyroxine (T 4) • E) Increased plasma levels of thyroid-stimulating hormone • Answer : E)

MCQ • 22 When planning to stop steroid, you should: • A. Stop steroid abruptly. • B. De-escalate the dose by 15 mg every other day. • C. De-escalate the dose by 5 mg every one week. • D. Any of the above. • Answer is c

MCQ • 23. Which of the following statements about antidiuretic hormone is true? • A) It is synthesized in the posterior pituitary gland • B) It increases salt and water reabsorption in the collecting tubules and ducts • C) It stimulates thirst • D) It has opposite effects on urine and plasma osmolality • Answer : D)

MCQ • 24. Which of the following hormones is not stored in its endocrineproducing gland? • A) T 4 • B) PTH • C) Aldosterone • D) ACTH • E) Insulin • Answer : C)

• 25 -Which of the following pituitary hormones has a chemical structure most similar to that of antidiuretic hormone? • A) Oxytocin • B) Adrenocorticotropic hormone • C) Thyroid-stimulating hormone • D) Follicle-stimulating hormone • E) Prolactin • Answer : A)

MCQ • 26 -In order for milk to flow from the nipple of the mother into the mouth of the nursing infant, which of the following must occur? • A) Myoepithelial cells must relax • B) Prolactin levels must fall • C) Oxytocin secretion from the posterior pituitary must take place • D) The baby’s mouth must develop a strong negative pressure over the nipple • E) All of the above • Answer : C)

MCQ • 27. Growth hormone secretion would most likely be suppressed under which of the following conditions? • A) Acromegaly • B) Gigantism • C) Deep Sleep • D) Exercise • E) Acute hyperglycemia • Answer : E)

MCQ • 28. Which of the following hormones is largely unbound to plasma proteins? • A) Cortisol • B) Thyroxine (T 4) • C) Antidiuretic hormone • D) Estradiol • E) Progesterone • Answer : C)

MCQ • 29. Which of the following hormones is both synthesized and stored in the pituitary gland? • A) Growth hormone (GH) • B) GH releasing hormone (GHRH) • C) ADH • D) Somatostatin • E) Somatomedin • Answer : A)

MCQ • 30 -A patient has a goiter associated with high plasma levels of both thyrotropin -releasing hormone (TRH) and thyroid-stimulating hormone (TSH). Her heart rate is elevated. This patient most likely has which of the following? • A) Endemic goiter • B) Hypothalamic tumor secreting large amounts of TRH • C) Pituitary tumor secreting large amounts of TSH • D) Graves’ disease • Answer : B)

• 31 -Which of the following findings would likely be reported in a patient with a deficiency in iodine intake? • A) Weight loss • B) Nervousness • C) Increased sweating • D) Increased synthesis of thyroglobulin • E) Tachycardia • Answer : D)

• 32 -A patient has hypothyroidism due to a primary abnormality in the thyroid gland. Increased plasma levels of which of the following would most likely be reported? • A) Cholesterol • B) Thyroxine-binding globulin • C) Reverse triiodothyronine (RT 3) D) Diiodotyrosine • E) Iodide • Answer : A)

• 33 -Insulin secretion is stimulated by all of the following except • a. Mannose • b. Glucagons • c. Noradrenaline • d. Leucine • e. Acetylcholine • Answer is c

• 34 -. All are true of ANP except • a. It causes natriuresis • b. It lowers BP • c. Circulating ANP has a short half life • d. ANP has the greatest affinity for the ANPR-B receptor on the glomerulus • e. It is released when atrial muscle is stretched • Answer

MCQ • 35. Concerning Ca metabolism • a. The net effect of PTH is to decrease serum PO 4 • b. Vitamin D decreases renal excretion of both Ca and PO 4 • c. Calcitonin is secreted by parathyroid chief cells • d. Insulin decreases bone formation • e. Thyroid hormones decrease Ca excretion in urine • Answer is a

MCQ • 36 With regard to adrenal function • a. The zona fasciculate secretes mainly aldosterone • b. The adrenal medulla is not essential to life • c. ACTH is the prime controller of secretion from zona glomerulosa • d. More than 85% of adrenal medullary secretion is NA • e. Hypernatraemia is associated with Mineralocorticoid deficiency • Answer is b

MCQ • 37 -a deficiency of parathyroid hormone is likely to lead to • a. low PO 4 • b. kidney stone formation • c. a self limiting illness • d. neuromuscular hyperexcitability • e. cystic bone disease • answer is d

MCQ 38 -A profile of high TSH, normal T 4 and T 3 may be defined as: • A. Lab artifact • B. Subclinical hypothyroidism • C. Either A or B • D. None of the above • Answer is c

MCQ 39 -A thyroid hormone profile of very low TSH, low T 4 and low T 3 is known as: • A. Primary thyrotoxicosis • B. Secondary hypothyroidism • C. Sick euthyroid syndrome • D. None of the above • Answer is b

MCQ 40 -Hashimoto disease characterized by the following except: • A. Autoimmunity against thyroid perioxidase • B. Tender goiter • C. Anti TPO positivity • D. Lymphocytic infiltration of the thyroid • Answer is b •

ENDOCRINE CASES

CASE SCENARIO

Case 1 • History: A 50 years old housewife complains of progressive weight gain of 20 pounds in 1 year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. • Physical examination: Vital signs include a temperature 96. 8 o. F, pulse 58/minute and regular, BP 110/60. She is moderately obese and speaks slowly and has a puffy face, with pale, cool, dry, and thick skin. The thyroid gland is not palpable. The deep tendon reflex time is delayed.

• Laboratory studies: CBC and differential WBC are normal. The serum T 4 concentration is 3. 8 ug/dl (N=4. 5 -12. 5), the serum TSH is 1 u. U/ml (N=0. 23. 5), and the serum cholesterol is 255 mg/dl (N<200). • 1. What is the likely diagnosis? Answer • There are certain features that are very suggestive for hypothyroidism such as: a deep voice delayed Achilles' tendon reflex time bradycardia

• Explain-Hypothalamic-Pituitary-Thyroid axis and interrelationship. • . What are the most likely causes? Answer Pituitary tumor Pituitary infarction Sarcoidosis, Histiocytosis X, Hemochromatosis, Metastatic carcinoma involving pituitary, hypothalamus or stalk, Rathke's cleft cyst, craniopharyngioma

• 7. What additional tests would help confirm the diagnosis? MRI with gadolinium enhancement to document the presence of a mass Baseline and dynamic anterior pituitary hormone testing for deficiencies and overproduction Testing for other tumor markers (alpha subunits)

• 8. What are the treatment options? Evaluate if secondary hypoadrenalism is present. If present treat simultaneously with the treatment of the hypothyroidism. Then treat the cause of the secondary hypothyroidism. Also evaluate whether hypogonadism and/or growth hormone deficiency is present and treat accordingly

Case (2)

• History: • A 35 year old nurse complained of nervousness, weakness, and palpitations with exertion for the past 6 months. Recently, she noticed excessive sweating and wanted to sleep with fewer blankets than her husband. She had maintained a normal weight of 120 pounds but was eating twice as much as she did 1 year ago. Menstrual periods have been regular but there was less bleeding.

• Physical examination: Pulse was 92/minute and BP was 130/60. She appeared anxious, with a smooth, warm, and moist skin, a fine tremor, a bounding cardiac apical impulse, a pulmonic flow murmur, and she couldn't rise from a deep knee bend without aid. Her thyroid contained 3 nodules, 2 on the right and one on the left with a total gland size of 60 grams (3 times normal size), all nodules being of firm consistency and there was no lymphadenopathy. Her eyes were not prominent (proptotic) and she had no focal skin thickening.

• Laboratory studies: Serum T 4=15. 6 ug/dl and serum T 3=250 ng/dl (N=80160). • 1. What is the level of thyroid function in this patient? Are additional diagnostic tests necessary to define the level of thyroid function and if so which one(s)? • Answer Hyperthyroid. Yes, TSH. 2. What are the symptoms that made you consider that diagnosis? Answer

• What is the most likely cause of this patient's illness? What tests are necessary to confirm its cause? Are antithyroid antibodies helpful? • Answer : Toxic multinodular goiter. A thyroid scan to verify the autonomy of the thyroid nodules. No. • . What are the treatment options? Radioactive iodine or surgery with antithyroid drug and iodine pretreatment

Case 3

• History A 64 -year-old man goes to his general practitioner (GP) because he has become increasingly overweight. He has gained 8 kg in weight over the past 6 months. He has noticed that he is constantly hungry. He has found that he is bruising easily. He finds it difficult to get up from his armchair or to climb stairs. He feels depressed and finds himself waking early in the mornings. He has had no previous physical or psychiatric illnesses. He is a retired miner and lives with his wife in a terraced house. He smokes 30 cigarettes per day and drinks 15 units of alcohol per week.

• Examination He is overweight particularly in the abdominal region. There are purple stretch marks on his abdomen and thighs. His skin is thin, and there are spontaneous bruises. His pulse is 76/min, regular, and blood pressure 168/104 mm. Hg. There is peripheral oedema. Otherwise, examination of his heart, respiratory and abdominal systems is normal. His neurological examination is otherwise normal, apart from some weakness in shoulder abduction and hip flexion.

INVESTIGATIONS: • Haemoglobin 13. 2 g/d. L (13. 3– 17. 7 g/d. L) • Mean corpuscular volume (MCV) 87 f. L (80– 99 f. L • White cell count 5. 2 % 109/L ( 3. 9– 10. 6 % 109/L • Platelets 237 % 109/L (150– 440 % 109/L • Sodium 138 mmol/L (135– 145 mmol/L • Potassium 3. 3 mmol/L (3. 5– 5. 0 mmol/L • Urea 6. 2 mmol/L ( 2. 5– 6. 7 mmol/L • Creatinine 113&mol/L (70– 120&mol/L

• Albumin 38 g/L (35– 50 g/L • Glucose 8. 3 mmol/L ( 4. 0– 6. 0 mmol/L • Bilirubin 16 mmol/L ( 3– 17 mmol/L • Alanine transaminase 24 IU/L (5– 35 IU/L • Alkaline phosphatase 92 IU/L (30– 300 IU/L • Gamma-glutamyl transpeptidase 43 IU/L ( 11– 51 IU/L • Urinalysis: – protein; – blood; '' glucose • Chest X-ray: normal • imaging (MRI) scan through the pituitary shows a hypointense microadenoma

Questions • • What is the likely diagnosis? • • How would you investigate and manage this patient?

• ANSWER • The symptoms and signs of proximal myopathy, striae and truncal obesity are features of Cushing’s syndrome. The hyperglycaemia and hypokalaemia would fit this diagnosis. In addition psychiatric disturbances, typically depression, may occur in Cushing’s syndrome.

Causes of Cushing syndrome: • . Cushing’s disease is due to a pituitary adenoma secreting adrenocorticotrophic hormone (ACTH) • ACTH secretion by a basophil adenoma of the anterior pituitary gland (Cushing’s disease). • Ectopic ACTH secretion, e. g. from a bronchial carcinoma, often causing a massive release of cortisol and a severe and rapid onset of symptoms. • Primary adenoma/carcinoma of the adrenal cortex (suppressed ACTH). • Iatrogenic: corticosteroid treatment. This is the commonest cause in day-to-day clinical practice.

• The first point is to establish is that this man has abnormal cortisol secretion. There should be loss of the normal diurnal rhythm with an elevated midnight cortisol level or increased urinary conjugated cortisol excretion. A dexamethasone suppression test would normally suppress cortisol excretion. It is then important to exclude common causes of abnormal cortisol excretion such as stress/depression or alcohol abuse. Measurement of ACTH levels distinguishes between adrenal (low ACTH) and pituitary/ectopic causes (high ACTH). His ACTH level is elevated. Bronchial carcinoma is a possibility as he is a heavy smoker and the onset of his Cushing’s syndrome has been rapid. However his chest X-ray is normal. In this man a magnetic resonance imaging (MRI) scan through the pituitary shows a hypointense microadenoma This can be treated surgically or by

GOOD LUCK