Endocrinology Practice Questions

Q: In which condition are hung-up reflexes typically observed?

Hypothyroidism. ***Hypothyroidism*** - **Hung-up reflexes** (or **Woltman's sign**) are characterized by a **slow relaxation phase** of deep tendon reflexes, a classic finding in hypothyroidism. - This delayed relaxation is due to altered muscle contraction and relaxation kinetics caused by **deficient thyroid hormones**. *Chorea* - Chorea is characterized by **brief, abrupt, irregular, unpredictable, non-stereotyped movements** that flow from one body part to another [1]. - Reflexes themselves are not typically "hung up" but may be difficult to elicit or appear irregular due to the involuntary movements. *Cerebral palsy* - Cerebral palsy is a group of permanent movement disorders that appear in early childhood and are typically characterized by **spasticity**, **ataxia**, or **dystonia**. - While reflex abnormalities are common, including **hyperreflexia** and sustained clonus, the specific finding of "hung-up reflexes" (slow relaxation) is not typical. *Cerebellar ataxia* - Cerebellar ataxia primarily affects **coordination, balance, and gait**, leading to dysmetria, dysdiadochokinesia, and intention tremor [2]. - Reflexes in cerebellar ataxia are often **normal** or can exhibit **pendular reflexes**, where the limb swings back and forth several times after being struck, rather than a delayed relaxation.

Q: Female on carbimazole therapy presents with sudden fever, rigors and sore throat. Which is the investigation of choice for this patient?

Check blood counts. **Check blood counts** * **Carbimazole** is a known cause of **agranulocytosis**, a severe reduction in **white blood cell count**, making a complete blood count (CBC) crucial for diagnosis. * The symptoms of **fever, rigors, and sore throat** are classic signs of infection due to severe **neutropenia**, necessitating urgent investigation of blood counts [1]. Rigors specifically represent shivering that occurs with a rapid rise in body temperature [1]. * *Check C-reactive protein* * **C-reactive protein (CRP)** is a general marker of inflammation and infection but does not provide specific information about white blood cell counts. * While CRP would likely be elevated in an infection, it wouldn't distinguish between a common infection and **carbimazole-induced agranulocytosis**. * *Take a throat swab* * A **throat swab** could identify a causative pathogen for the **sore throat**, but it would not reveal the underlying cause of the patient's susceptibility to infection. * Prioritizing a throat swab over a CBC could delay the diagnosis of a life-threatening condition like **agranulocytosis**. * *Treat for malaria* * There is no information in the clinical scenario to suggest **malaria**, such as travel history to endemic areas. * Assuming malaria without proper diagnostic workup, especially in the context of carbimazole use, would be an inappropriate and potentially dangerous medical decision.

Q: A patient with diabetes mellitus for the past 5 years presents with vomiting and abdominal pain. She is non-compliant with medication and appears dehydrated. Investigations revealed a blood sugar value of 500 mg/dl and the presence of ketone bodies. What is the next best step in management of this patient?

Intravenous fluids with regular insulin. Detailed management of diabetic ketoacidosis (DKA) requires both fluid resuscitation and insulin therapy. ***Intravenous fluids with regular insulin*** - The patient presents with classic signs of **diabetic ketoacidosis (DKA)**: hyperglycemia (blood sugar 500 mg/dl), ketone bodies, dehydration, and a history of diabetes non-compliance [1]. - Initial management for DKA involves aggressive **intravenous fluid resuscitation** to correct dehydration and then **intravenous regular insulin** to lower blood glucose and resolve ketosis [2]. *Intravenous fluids with long-acting insulin* - While fluids are essential, **long-acting insulin** is not appropriate for the acute management of DKA because its slow onset of action makes it inefficient for rapidly correcting hyperglycemia and ketosis. - **Regular insulin** is preferred as it has a quicker onset and shorter duration, allowing for more precise titration in an acute setting [2]. *Intravenous fluids* - Although crucial for correcting **dehydration** and improving renal perfusion, fluids alone will not address the underlying **insulin deficiency** and **ketosis** that define DKA. - Without insulin, the body will continue to produce ketones, exacerbating acidosis [3]. *Intravenous insulin* - Giving intravenous insulin without prior or concomitant **fluid resuscitation** can be dangerous, as it can worsen **hypovolemia** and potentially lead to circulatory collapse by shifting glucose and potassium into cells. - It is critical to first restore **circulating volume** before initiating insulin therapy [2].

Q: A patient presents with polyuria following total hypophysectomy. Laboratory results show Na+ levels at 155 mEq/L and urine osmolarity at 200 mOsm/L. What is the definitive management for this patient?

Lifelong DDAVP supplementation. ### Lifelong DDAVP supplementation - The patient's **polyuria** after **total hypophysectomy**, coupled with **hypernatremia (Na+ 155 mEq/L)** and **low urine osmolarity (200 mOsm/L)**, strongly indicates **central diabetes insipidus (DI)** due to **ADH deficiency** [1]. - **Desmopressin (DDAVP)** is a synthetic analog of **ADH** and is the definitive treatment for central DI, replacing the missing hormone, and addressing the lifelong deficiency [1]. ### No treatment required as receptors are upset - This is incorrect as untreated **diabetes insipidus** can lead to severe **dehydration, hypernatremia, and neurological complications**, making intervention critical [2]. - The symptoms and lab findings indicate a clear deficiency, not merely "upset" receptors, which requires definitive management to prevent life-threatening complications. ### Thiazides for a limited duration of 2 weeks - **Thiazide diuretics** are used in **nephrogenic diabetes insipidus** to induce mild volume depletion, which can increase water reabsorption in the proximal tubule [1]. - However, they are not the definitive treatment for **central DI** where the primary problem is a lack of **ADH**, and using them for a *limited duration* would not address a lifelong condition. ### DDAVP for a limited duration of 2 weeks - While **DDAVP** is the correct treatment for **central DI**, the condition resulting from a total hypophysectomy is **permanent**. - Therefore, treatment for only a *limited duration* would lead to the recurrence of symptoms, and potentially life-threatening complications, making lifelong management essential.

Q: Which of the following is commonly seen in Pituitary apoplexy?

Headache. ***Headache*** - **Severe headache** is the most common symptom of pituitary apoplexy, resulting from the sudden expansion of a pituitary mass due to hemorrhage or infarction [1]. - The rapid increase in pressure within the sella turcica, especially on the **dura mater**, causes intense pain. *Hypertension* - While stress can elevate blood pressure, **hypertension** is not a characteristic or direct symptom of acute pituitary apoplexy itself. - Instead, the condition often leads to **adrenal insufficiency**, which is associated with hypotension [1]. *Hypotension* - **Hypotension** is a common and serious manifestation of pituitary apoplexy, often due to acute **adrenal insufficiency** caused by the destruction of ACTH-producing cells [1]. - Reduced ACTH leads to decreased cortisol production, impairing vascular tone and fluid balance. *Vomiting* - **Vomiting** is a common symptom in pituitary apoplexy, often accompanying the severe headache. - It results from the increased **intracranial pressure** and irritation of pathways in the brainstem.

Q: A 32-year-old woman complains of amenorrhea since the delivery of a baby 15 months previously, despite the fact that she did not breastfeed her baby. The delivery was complicated by excessive hemorrhage that required a transfusion of 2.5 liters of blood. She has also been fatigued and has gained an additional 4.5Kg since the baby was born. Laboratory data show the following: Serum LH < 1 IU/L (normal, 4-24 IU/L) Serum estradiol 5 pg/mL (normal, 20 - 100 pg/mL) Serum TSH 0.1 mU/L (normal, 0.5 - 5 mU/L) Serum GH 3 ng/mL (normal, < 5 ng/mL) Serum ACTH 28 pg/mL (normal, 10 - 50 pg/mL) Serum prolactin 2 ng/mL (normal, < 20 ng/mL). Injection of 500 μg of TRH failed to produce the expected rise in both serum TSH and prolactin. Which of the following diagnoses most likely explains the findings in this patient?

Hypopituitarism due to Sheehan's syndrome. ### Hypopituitarism due to Sheehan's syndrome - The patient's history of **postpartum hemorrhage** followed by amenorrhea, fatigue, and weight gain, along with low levels of **LH**, **estradiol**, **TSH**, and **prolactin**, despite normal ACTH and GH, points towards anterior pituitary dysfunction due to **ischemic necrosis** caused by Sheehan's syndrome [1]. - The failure of **TRH stimulation** to increase TSH and prolactin further supports a pituitary origin, as the pituitary is unable to respond due to damage. ### Hashimoto's thyroiditis - This condition primarily causes **hypothyroidism**, characterized by elevated TSH and low thyroid hormones, which is inconsistent with the patient's low TSH. - It does not explain the **gonadotropin deficiency** (low LH and estradiol) or the history of postpartum hemorrhage leading to multi-hormone deficiencies. ### Isolated gonadotropin deficiency - While the patient exhibits **amenorrhea** and low LH and estradiol, this diagnosis does not account for the **low TSH** [3] or the historical context of a severe postpartum hemorrhage. - Isolated gonadotropin deficiency does not explain the lack of TSH and prolactin response to TRH. ### Primary amenorrhea - This refers to the absence of menstruation by age 15 (with breast development) or 13 (without breast development) in a patient who has never menstruated, which is not applicable to a 32-year-old woman who has delivered a baby. - The patient's presentation is secondary amenorrhea, occurring after menarche and delivery, and is associated with other pan-hypopituitary features [4]. ### Pituitary apoplexy - Pituitary apoplexy typically presents with the **sudden onset** of severe headache, visual disturbances, and ophthalmoplegia due to acute hemorrhage or infarction of a pituitary adenoma. - This patient's symptoms are more chronic and progressive, evolving over 15 months, and lack the acute, severe presentation typical of apoplexy [2].

Q: Which of the following is not seen in MEN 2B syndrome?

Parathyroid adenoma. ***Parathyroid adenoma*** - **Parathyroid adenomas**, leading to hyperparathyroidism, are characteristic of **MEN 2A syndrome**, not MEN 2B [1]. - While both MEN 2A and 2B involve mutations in the **RET proto-oncogene**, the specific clinical manifestations differ significantly. *Megacolon* - **Megacolon** (due to intestinal ganglioneuromatosis) is a recognized feature of **MEN 2B syndrome**. - This condition involves abnormal nerve ganglion cells in the intestine, leading to motility issues. *Mucosal neuroma* - **Mucosal neuromas** on the tongue, lips, and eyelids are a hallmark clinical sign of **MEN 2B syndrome**. - These benign growths are often one of the earliest and most recognizable features. *Marfanoid habitus* - **Marfanoid habitus**, characterized by a tall, slender build with long limbs and arachnodactyly, is a common physical finding in **MEN 2B syndrome**. - This connective tissue abnormality helps distinguish MEN 2B from other MEN syndromes.

Q: Which is the most common pancreatic endocrine neoplasm?

Insulinoma. ***Insulinoma*** - It is the **most common pancreatic endocrine neoplasm**, characterized by excessive insulin production leading to hypoglycemia. - Most patients present with **symptoms of hypoglycemia**, such as sweating, confusion, and palpitations due to overproduction of insulin [1]. *Gastrinoma* - Generally implicated in **Zollinger-Ellison syndrome**, it causes excessive gastric acid secretion, leading to severe ulcers but is less common than insulinoma. - Associated with **diarrhea and abdominal pain**, not typically causing hypoglycemia [1]. *Glucagonoma* - Rarely seen, it causes **hyperglycemia** and characteristic **necrotizing migratory erythema**, rather than hypoglycemic episodes. - Comprises a minority of pancreatic endocrine tumors and is not the most common type. *VIPoma* - Produces **vasoactive intestinal peptide**, leading to profuse watery diarrhea and severe electrolyte imbalance. - It is uncommon compared to insulinoma and primarily causes gastrointestinal symptoms rather than hypoglycemia.

Q: Patient has fatigue but is not gaining weight. Body was warm. Which investigation is most likely to be informative?

Low TSH with elevated T3 and T4. ***Low TSH with elevated T3 and T4*** - This pattern is indicative of **hyperthyroidism**, which aligns with symptoms of **fatigue** (despite increased metabolic rate due to catabolic effects), not gaining weight, and feeling warm, as thyroid hormones regulate metabolism and body temperature [1]. - An elevated **Free T4** and **Free T3** with a suppressed **TSH** confirms a diagnosis of primary hyperthyroidism [1]. *High TSH with normal T3 and T4* - This suggests **subclinical hypothyroidism** (also known as latent hypothyroidism), where the thyroid gland is beginning to fail, but **peripheral thyroid hormone levels** are still within the normal range due to thyroid compensatory mechanisms [1]. - Patients with subclinical hypothyroidism are usually asymptomatic (as the body has compensated to produce sufficient amounts of T3 and T4), but when symptoms do emerge, they are those of **hypothyroidism**, such as weight gain and cold intolerance, which contradict the patient's presentation [1]. *High TSH with euthyroid status* - **Euthyroid** means having normal thyroid function, therefore this option is practically identical to "High TSH with normal T3 and T4". - This implies **subclinical hypothyroidism**, which typically presents with normal body temperature and potential for weight gain, not fatigue without weight gain alongside a warm body [1]. *Increased T3 with decreased T4 levels* - This specific pattern is rare and could be indicative of certain conditions affecting thyroid hormone metabolism, such as **T4 to T3 conversion issues** or specific forms of **thyroiditis**, but is not typical of a primary thyroid disorder presenting with the given symptoms. - While an elevated T3 might suggest some hyperthyroid features, the decreased T4 complicates the picture and does not directly support the clinical presentation of *unexplained fatigue* and *warm body* in typical thyroid disease.

Q: A 55-year-old postmenopausal woman presents with chronic low backache of 6 months duration. She has no history of trauma. What is the most likely diagnosis?

Osteoporosis. ***Osteoporosis*** - **Postmenopausal women** are at a high risk of developing osteoporosis due to **estrogen deficiency**, which leads to accelerated bone loss [1]. - **Chronic low backache** without trauma in this demographic suggests **vertebral compression fractures**, a common complication of osteoporosis [1]. *Hurler's syndrome* - This is a **lysosomal storage disorder** (mucopolysaccharidosis type I) that manifests in **childhood** with skeletal deformities, coarse facial features, and developmental delays. - It would not present as new-onset chronic low backache in a 55-year-old adult. *Paget’s disease* - Paget's disease involves **localized abnormal bone remodeling**, leading to enlarged and weakened bones [2]. - While it can cause bone pain, it's characterized by elevated **alkaline phosphatase** and often affects the pelvis, skull, or long bones, and a simple low backache presentation in a postmenopausal woman points more strongly to osteoporosis [2], [3]. *Renal osteodystrophy* - This condition is a complication of **chronic kidney disease**, resulting from imbalances in calcium, phosphate, parathyroid hormone, and vitamin D metabolism. - It would require a history of **renal dysfunction** and the low backache would likely be accompanied by other symptoms of kidney failure or bone pain related to specific lesions, which are not mentioned.

Question 1

In which condition are hung-up reflexes typically observed?

Accepted Answer

Hypothyroidism

Answer

Cerebral palsy

Answer

Chorea

Answer

Cerebellar ataxia

Question 2

Female on carbimazole therapy presents with sudden fever, rigors and sore throat. Which is the investigation of choice for this patient?

Accepted Answer

Check blood counts

Answer

Check C-reactive protein

Answer

Take a throat swab

Answer

Treat for malaria

Question 3

A patient with diabetes mellitus for the past 5 years presents with vomiting and abdominal pain. She is non-compliant with medication and appears dehydrated. Investigations revealed a blood sugar value of 500 mg/dl and the presence of ketone bodies. What is the next best step in management of this patient?

Accepted Answer

Intravenous fluids with regular insulin

Answer

Intravenous fluids

Answer

Intravenous insulin

Answer

Intravenous fluids with long-acting insulin

Question 4

A patient presents with polyuria following total hypophysectomy. Laboratory results show Na+ levels at 155 mEq/L and urine osmolarity at 200 mOsm/L. What is the definitive management for this patient?

Accepted Answer

Lifelong DDAVP supplementation

Answer

No treatment required as receptors are upset

Answer

Thiazides for a limited duration of 2 weeks

Answer

DDAVP for a limited duration of 2 weeks

Question 5

Which of the following is commonly seen in Pituitary apoplexy?

Accepted Answer

Headache

Answer

Hypertension

Answer

Hypotension

Answer

Vomiting

Question 6

A 32-year-old woman complains of amenorrhea since the delivery of a baby 15 months previously, despite the fact that she did not breastfeed her baby. The delivery was complicated by excessive hemorrhage that required a transfusion of 2.5 liters of blood. She has also been fatigued and has gained an additional 4.5Kg since the baby was born. Laboratory data show the following: Serum LH < 1 IU/L (normal, 4-24 IU/L) Serum estradiol 5 pg/mL (normal, 20 - 100 pg/mL) Serum TSH 0.1 mU/L (normal, 0.5 - 5 mU/L) Serum GH 3 ng/mL (normal, < 5 ng/mL) Serum ACTH 28 pg/mL (normal, 10 - 50 pg/mL) Serum prolactin 2 ng/mL (normal, < 20 ng/mL). Injection of 500 μg of TRH failed to produce the expected rise in both serum TSH and prolactin. Which of the following diagnoses most likely explains the findings in this patient?

Accepted Answer

Hypopituitarism due to Sheehan's syndrome

Answer

Pituitary apoplexy

Answer

Isolated gonadotropin deficiency

Answer

Hashimoto's thyroiditis

Answer

Primary amenorrhea

Question 7

Which of the following is not seen in MEN 2B syndrome?

Accepted Answer

Parathyroid adenoma

Answer

Mucosal neuroma

Answer

Marfanoid habitus

Answer

Megacolon

Question 8

Which is the most common pancreatic endocrine neoplasm?

Accepted Answer

Insulinoma

Answer

Gastrinoma

Answer

VIPoma

Answer

Glucagonoma

Question 9

Patient has fatigue but is not gaining weight. Body was warm. Which investigation is most likely to be informative?

Accepted Answer

Low TSH with elevated T3 and T4

Answer

High TSH with normal T3 and T4

Answer

High TSH with euthyroid status

Answer

Increased T3 with decreased T4 levels

Question 10

A 55-year-old postmenopausal woman presents with chronic low backache of 6 months duration. She has no history of trauma. What is the most likely diagnosis?

Accepted Answer

Osteoporosis

Answer

Hurler's syndrome

Answer

Paget’s disease

Answer

Renal osteodystrophy

Endocrinology — MCQs

Endocrinology — MCQs

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