Endocrinology — MCQs
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A patient is diagnosed with acromegaly. Transsphenoidal surgery is not feasible. Which of the following drugs is preferred for the medical management of this patient?
A diabetic patient developed DVT with a necrolytic migratory rash. What is the most likely diagnosis?
A 28-year-old female presents with palpitations, heat intolerance, weight loss of 8 kg over 3 months, and tremors. Examination reveals diffuse thyroid enlargement, exophthalmos, and pretibial myxedema. Thyroid function tests show TSH <0.01 mIU/L, free T4 28 ng/dL (normal 5-12), and free T3 elevated. TSH receptor antibodies are positive. What is the most appropriate definitive treatment?
Multiple lytic lesions on skull are seen in which thyroid carcinoma?
A 30-year-old man develops an increase in shoe size with coarse facies and large hands. IGF1 is elevated. What is the investigation of choice?
A 56-year-old diabetic patient is currently on Metformin and Insulin Glargine. His HbA1c is 8.2 %, indicating suboptimal glycemic control. Echocardiography reveals a reduced ejection fraction (EF) of 35 %. Which of the following is the most appropriate agent to add to his current regimen?
Hyperpigmentation in Addison's disease is due to increased secretion of:
A known type 1 diabetic presents with glucose 799 mg/dL, Na+ 128 mEq/L, Cl- 88 mEq/L, and signs of dehydration. Which of the following is NOT used in the initial management?
A patient presents with salt wasting, craving, hyperkalemia, metabolic acidosis, and skin pigmentation. What is the most likely diagnosis?
A 60-year-old patient presents with pain in multiple bones and a history of increased hat size. On examination, some bones feel warm to touch. Biochemical investigations show normal serum calcium, phosphate, and parathyroid hormone (PTH) levels, but markedly elevated alkaline phosphatase (ALP). What is the most likely diagnosis
Endocrinology Indian Medical PG Practice Questions and MCQs
Question 1301: A patient is diagnosed with acromegaly. Transsphenoidal surgery is not feasible. Which of the following drugs is preferred for the medical management of this patient?
- A. Terlipressin
- B. Ketoconazole
- C. Leuprolide
- D. Lanreotide depot formulation (Correct Answer)
Explanation: ***Lanreotide depot formulation***- It is a **somatostatin analog** (SSA) and a first-line medical therapy for acromegaly, particularly when surgery fails or is contraindicated [1].- SSAs normalize **GH (Growth Hormone)** and **IGF-1 (Insulin-like Growth Factor-1)** levels by inhibiting pituitary GH secretion [1].*Terlipressin*- It is primarily an analog of **vasopressin** used to treat **esophageal variceal bleeding** and hepatorenal syndrome.- It has no role in reducing pituitary growth hormone hypersecretion characteristic of acromegaly.*Ketoconazole*- It is an **antifungal agent** that also inhibits **steroidogenesis** (glucocorticoids, androgens).- Its primary hormonal use is in treating **Cushing's syndrome** (due to cortisol inhibition), not acromegaly.*Leuprolide*- This is a **GnRH agonist** used primarily to treat conditions like **prostate cancer**, **endometriosis**, and **precocious puberty**.- It acts on the hypothalamic-pituitary-gonadal axis and does not directly target GH-secreting tumors.
Question 1302: A diabetic patient developed DVT with a necrolytic migratory rash. What is the most likely diagnosis?
- A. VIPoma
- B. Insulinoma
- C. Gastrinoma
- D. Glucagonoma (Correct Answer)
Explanation: ***Glucagonoma***- This paraneoplastic syndrome, caused by excessive glucagon secretion, is classically associated with the triad of **diabetes mellitus** (due to glucagon's counter-regulatory effect), **necrolytic migratory erythema (NME)**, and a high incidence of **venous thrombosis** (DVT/PE).- The classic rash, **NME**, is an erythematous, scaling rash that begins peripherally and migrates, often causing eroded, painful lesions [1].*Insulinoma*- The primary manifestation is **hypoglycemia** (Whipple's triad), leading to neuroglycopenic symptoms like confusion and seizures.- This tumor does not cause the characteristic **necrolytic migratory rash** or have a strong association with DVT.*Gastrinoma*- Gastrinomas cause **Zollinger-Ellison syndrome**, characterized by severe, refractory **peptic ulcer disease** (PUD) and chronic diarrhea.- The clinical presentation lacks the key features of hyperglycemia, DVT, and **necrolytic migratory erythema (NME)**.*VIPoma*- VIPomas cause the **WDHA syndrome** (**W**atery **D**iarrhea, **H**ypokalemia, **A**chlorhydria), leading to profound dehydration and electrolyte imbalances.- This tumor is not associated with the pathogenesis of **necrolytic migratory erythema** or the hypercoagulable state responsible for DVT.
Question 1303: A 28-year-old female presents with palpitations, heat intolerance, weight loss of 8 kg over 3 months, and tremors. Examination reveals diffuse thyroid enlargement, exophthalmos, and pretibial myxedema. Thyroid function tests show TSH <0.01 mIU/L, free T4 28 ng/dL (normal 5-12), and free T3 elevated. TSH receptor antibodies are positive. What is the most appropriate definitive treatment?
- A. Propylthiouracil for 6 months
- B. Immediate thyroidectomy
- C. Radioactive iodine ablation (Correct Answer)
- D. Beta-blockers only
Explanation: ***Radioiodine ablation*** - Radioiodine (I-131) ablation is a highly effective and widely used definitive treatment for **Graves' disease**, especially in young adults, offering a permanent cure by destroying the overactive thyroid tissue [1], [3]. - Although it may sometimes worsen pre-existing **Graves' ophthalmopathy**, it is generally preferred over surgery for its non-invasive nature and relative ease of administration [3]. *Total Thyroidectomy* - Thyroidectomy is an alternative definitive treatment and is preferred when the patient has a very large **goiter** causing compressive symptoms, coexisting suspicious **thyroid nodules**, or severe, progressive **Graves' ophthalmopathy** [2]. - While curative, it is a surgical procedure carrying risks such as injury to the **recurrent laryngeal nerve** and developing **hypoparathyroidism** [3]. *Methimazole* - Methimazole is a short-to-long term medical anti-thyroid drug (ATD) used to restore a **euthyroid state**, often used as an initial therapy before definitive treatment [3]. - It is **not considered definitive** as the relapse rate upon cessation is high, and continuous drug use may lead to side effects like **agranulocytosis** or hepatotoxicity [3]. *Propylthiouracil* - PTU is an ATD primarily reserved for specific situations, such as treatment during the **first trimester of pregnancy** (due to lower teratogenic risk) or management of a **thyroid storm** [3]. - Similar to Methimazole, it is not a definitive cure and carries a higher risk of **severe hepatotoxicity** compared to Methimazole, limiting its use in routine treatment [3].
Question 1304: Multiple lytic lesions on skull are seen in which thyroid carcinoma?
- A. Follicular carcinoma (Correct Answer)
- B. Thyroid lymphoma
- C. Papillary carcinoma thyroid
- D. Hurthle cell carcinoma
Explanation: ***Follicular carcinoma*** - Follicular thyroid carcinoma (FTC) classically spreads hematogenously to distant sites, most commonly the **bone (skull, spine, pelvis)** and lungs. - Bone metastases, especially in the skull, are typically **lytic** and may present as solitary or multiple lesions with a characteristic **"cannonball" appearance** on imaging if involving the lungs. ***Papillary carcinoma thyroid*** - Papillary thyroid carcinoma (PTC) predominantly spreads locally via **lymphatics** to regional neck lymph nodes, rarely causing distant metastases early in the disease course. - Distant metastases, when they occur, are usually to the lungs (small micronodules) and are less common as lytic skull lesions compared to FTC. ***Hurthle cell carcinoma*** - Hurthle cell carcinoma (a variant of follicular carcinoma) also has a high propensity for **hematogenous spread** to bone and lung. - While it can cause lytic bone lesions, it is best classified under the broader category of follicular carcinoma for its metastatic pattern, but FTC is the most common association for lytic skull lesions among the choices. ***Thyroid lymphoma*** - Thyroid lymphoma is rare and usually presents as a **rapidly enlarging thyroid mass** in an older patient, often associated with a background of Hashimoto's thyroiditis. - It typically causes diffuse thyroid involvement and local invasion into the neck structures; distant metastases, especially lytic skull lesions, are highly **uncommon**.
Question 1305: A 30-year-old man develops an increase in shoe size with coarse facies and large hands. IGF1 is elevated. What is the investigation of choice?
- A. Failure to suppress IGF-1 by OGTT
- B. GH levels
- C. Failure to suppress GH by OGTT (Correct Answer)
- D. IGF-1 levels
Explanation: ***Failure to suppress GH by OGTT*** - This is the **gold standard dynamic test** for confirming acromegaly, as it proves autonomous and unregulated **Growth Hormone (GH)** secretion [1]. - In healthy individuals, glucose load suppresses GH levels (typically to <1 ng/mL), but this suppression fails in patients with GH-secreting tumors [1]. *IGF-1 levels* - While highly sensitive for screening and monitoring, elevated **Insulin-like Growth Factor 1 (IGF-1)** levels alone are not definitive for diagnosis [2]. - IGF-1 levels must be confirmed with a dynamic test because they can be influenced by other factors like malnutrition or chronic liver failure [2]. *Failure to suppress IGF-1 by OGTT* - The definitive OGTT suppression test measures the suppression of **GH**, not IGF-1; IGF-1 reflects integrated GH production [1]. - While IGF-1 levels are used for diagnosis and monitoring, measuring its failure to suppress during OGTT is not the primary definition of diagnostic test failure. *GH levels* - A single random measurement of **Growth Hormone (GH)** is unreliable for diagnosis because GH is secreted in a highly pulsatile manner [1]. - Dynamic testing, such as the **Oral Glucose Tolerance Test (OGTT)**, is mandatory to confirm the pathological non-suppressibility of GH [1].
Question 1306: A 56-year-old diabetic patient is currently on Metformin and Insulin Glargine. His HbA1c is 8.2 %, indicating suboptimal glycemic control. Echocardiography reveals a reduced ejection fraction (EF) of 35 %. Which of the following is the most appropriate agent to add to his current regimen?
- A. Sitagliptin
- B. Empagliflozin (Correct Answer)
- C. Glimepiride
- D. Pioglitazone
Explanation: ***Empagliflozin*** - Empagliflozin, an SGLT2 inhibitor, is the preferred agent due to its confirmed benefit in reducing **cardiovascular mortality** and **hospitalization for heart failure** (HFrEF, EF 35%). - Current guidelines recommend SGLT2 inhibitors as the **first-line add-on** for patients with Type 2 DM and established HFrEF, regardless of baseline glycemic control. *Pioglitazone* - Thiazolidinediones like Pioglitazone are **contraindicated** in patients with symptomatic or established heart failure (NYHA Class III or IV, which this patient likely approaches) due to the risk of **fluid retention** [1]. - This fluid retention can worsen the patient's existing **reduced ejection fraction** and precipitate acute decompensation [1]. *Glimepiride* - Sulfonylureas significantly increase the risk of **hypoglycemia**, which can be dangerous, especially in patients with co-existing severe cardiac disease. - Glimepiride offers no benefit in reducing **cardiovascular events** or **heart failure hospitalization** compared to the benefits provided by SGLT2 inhibitors. *Sitagliptin* - DPP-4 inhibitors are generally **weight and CV neutral** (aside from Saxagliptin, which is associated with increased HF risk in some studies). - They lack the robust evidence of **cardioprotective and renovasculoprotective effects** seen with SGLT2 inhibitors and are consequently suboptimal for a patient with established HFrEF.
Question 1307: Hyperpigmentation in Addison's disease is due to increased secretion of:
- A. C. Aldosterone
- B. D. Renin
- C. B. ACTH (Correct Answer)
- D. A. Cortisol
Explanation: ***ACTH*** - In **primary adrenal insufficiency** (Addison's disease), low cortisol production results in loss of negative feedback to the pituitary gland, leading to massively increased secretion of **ACTH** (Adrenocorticotropic Hormone) [1]. - ACTH is synthesized from the precursor molecule **Pro-opiomelanocortin (POMC)**. Cleavage of POMC also generates Melanocyte-Stimulating Hormone (MSH) (or ACTH itself acts like MSH), which stimulates melanocytes, causing **hyperpigmentation** [1]. *Cortisol* - Cortisol levels are **low** in Addison's disease because of adrenal gland destruction, which is the underlying pathological issue [2]. - Cortisol is a glucocorticoid and its primary role is metabolic; it does not directly stimulate **melanogenesis**. *Aldosterone* - Aldosterone, a mineralocorticoid, is also deficient in primary Addison's disease, leading to **salt-wasting** and electrolyte disturbances (hyponatremia, hyperkalemia) [2]. - Aldosterone's synthesis pathway is distinct from that of the pituitary hormone ACTH and therefore does not influence **skin pigmentation**. *Renin* - Renin levels are often **elevated** in Addison's disease due to hypovolemia and hypotension resulting from aldosterone deficiency (activation of the **Renin-Angiotensin-Aldosterone System**) [3]. - Renin is an enzyme secreted by the kidney and has no direct mechanism or shared precursor pathway related to stimulating **melanocytes**.
Question 1308: A known type 1 diabetic presents with glucose 799 mg/dL, Na+ 128 mEq/L, Cl- 88 mEq/L, and signs of dehydration. Which of the following is NOT used in the initial management?
- A. 0.9 % Normal saline
- B. Potassium monitoring
- C. 3 % Saline (Correct Answer)
- D. IV infusion insulin
Explanation: Hypotonic conditions in Diabetic Ketoacidosis (DKA) are typically addressed with isotonic fluids. 3% saline is not used in initial management because it is reserved for severe cerebral edema or profound hypovolemia [3]. The immediate priority for fluid resuscitation in DKA is often 0.9% Normal Saline to correct volume depletion and hypotonicity [2], [4]. *0.9 % Normal saline* - This is essential for volume resuscitation to correct the severe dehydration (due to osmotic diuresis) and is the standard initial fluid administered in DKA [1], [2]. - It helps restore effective circulating volume and is initiated before insulin therapy to prevent vascular collapse [4]. *IV infusion insulin* - After initial fluid therapy is initiated, IV regular insulin infusion is crucial to transition the patient from a catabolic to an anabolic state, stopping ketone production and lowering blood glucose levels [2]. - Insulin therapy must be delayed until fluid resuscitation begins to prevent vascular collapse [4]. *Potassium monitoring* - Continuous and careful potassium monitoring is vital because acidosis and cellular shifts lead to rapid changes in serum potassium levels [2], [3]. - Potassium supplementation is often required if the serum potassium is < 5.5 mmol/L (or 5.2 mEq/L) to prevent life-threatening cardiac arrhythmias [2].
Question 1309: A patient presents with salt wasting, craving, hyperkalemia, metabolic acidosis, and skin pigmentation. What is the most likely diagnosis?
- A. Addison's disease (Correct Answer)
- B. Pheochromocytoma
- C. Cushing's syndrome
- D. Conn's syndrome
Explanation: ***Addison's disease*** - The features (salt wasting, hyperkalemia, metabolic acidosis, and skin pigmentation) are hallmarks of **primary adrenal insufficiency** (Addison's disease) [1], [2]. - **Skin pigmentation** (due to increased ACTH/MSH) and **salt wasting** (due to cortisol and aldosterone deficiency) are key differentiating points [2]. *Cushing's syndrome* - This condition is caused by **excess glucocorticoids** and typically presents with central obesity, moon facies, hypertension, and hypokalemia [3]. - It is characterized by **fluid retention** and suppressed ACTH (in secondary/tertiary causes), entirely opposite to the salt wasting seen here [3]. *Conn's syndrome* - Conn's syndrome is **primary hyperaldosteronism**, leading to sodium retention, **hypertension**, **hypokalemia**, and metabolic alkalosis [1]. - The presentation includes **hypokalemia** and **alkalosis**, which directly contradict the hyperkalemia and acidosis noted in the patient. *Pheochromocytoma* - This is a catecholamine-secreting tumor leading to episodic or sustained **hypertension**, palpitations, headaches, and sweating. - It primarily affects the cardiovascular system and does not cause the **salt wasting** or **hyperkalemia** profile seen in this patient.
Question 1310: A 60-year-old patient presents with pain in multiple bones and a history of increased hat size. On examination, some bones feel warm to touch. Biochemical investigations show normal serum calcium, phosphate, and parathyroid hormone (PTH) levels, but markedly elevated alkaline phosphatase (ALP). What is the most likely diagnosis
- A. Multiple myeloma
- B. Osteosarcoma
- C. Osteomalacia
- D. Paget's disease of bone (Correct Answer)
Explanation: ***Paget's disease of bone*** - The presentation with pain in multiple bones, **increased hat size** (due to skull involvement), and markedly elevated **Alkaline Phosphatase (ALP)** with normal calcium and phosphate is the classic biochemical profile [1]. - The sensation of warmth over the bones is caused by increased bone turnover and subsequent **hypervascularity** (increased blood flow) in the affected areas [1]. *Osteosarcoma* - This is a highly malignant bone tumor, typically presenting as localized pain and a mass, especially in the **metaphysis of long bones** (e.g., around the knee). - It does not usually present with the widespread, multiple bone involvement or the classic sign of increased **hat size** seen in this older patient. Paget's disease accounts for most cases of osteosarcoma occurring in older populations [1]. *Multiple myeloma* - This plasma cell malignancy involves the axial skeleton, commonly presenting with **anemia**, **renal failure**, and **hypercalcemia** (due to lytic bone lesions), which is ruled out by the normal calcium level here [2]. - The hallmark is the presence of a serum or urine **M-protein** (paraprotein), and ALP elevation is usually mild or absent unless related to pathological fracture [2]. *Osteomalacia* - This condition is characterized by defective mineralization, leading to low or low-normal serum **calcium** and/or **phosphate** levels, which contradicts the normal biochemical profile presented [3]. - While ALP can be elevated due to secondary hyperparathyroidism or increased osteoblast activity, the findings of severe widespread thickening and increased hat size are not typical [3].
Practice by Chapter
Diabetes Mellitus
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Thyroid Disorders
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Adrenal Gland Disorders
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Pituitary Disorders
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Calcium and Bone Metabolism
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Reproductive Endocrinology
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Lipid Disorders
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Endocrine Hypertension
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Multiple Endocrine Neoplasia
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Obesity and Metabolic Syndrome
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Endocrine Emergencies
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