Endocrinology Practice Questions

Q: 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?

Radioactive iodine ablation. ***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].

Q: 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?

Failure to suppress GH by OGTT. ***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].

Q: 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?

Empagliflozin. ***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.

Q: 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?

3 % Saline. 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].

Q: A patient presents with salt wasting, craving, hyperkalemia, metabolic acidosis, and skin pigmentation. What is the most likely diagnosis?

Addison's disease. ***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.

Q: 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

Paget's disease of bone. ***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].

Q: All are true regarding this picture of 16-year-old boy except: (Recent NEET Pattern 2016-17)

ACTH excess. **ACTH excess** - **ACTH excess** (as seen in Cushing's disease or ectopic ACTH production) primarily causes symptoms related to **cortisol hypersecretion**, such as central obesity, moon facies, striae, and muscle weakness. - Gynecomastia is **not a typical clinical manifestation** of ACTH excess. *Gynecomastia is defined as >2 cm breast tissue* - Gynecomastia is classically defined as breast glandular tissue **greater than 2 cm in diameter**, palpable beneath the nipple-areolar complex. - This definition helps differentiate true gynecomastia from simple adipomastia (excess fatty tissue). *Unilateral in pubertal boys* - Pubertal gynecomastia, which occurs due to hormonal fluctuations during adolescence, is often **asymmetrical** or unilateral initially. - It affects about 50-70% of pubertal boys and usually resolves spontaneously within 6 months to 2 years. *Seen in CRF* - **Chronic Renal Failure (CRF)** is a known cause of gynecomastia due to several factors, including altered **estrogen-androgen ratios**, decreased clearance of pituitary hormones (like prolactin), and uremia-induced Leydig cell dysfunction. - This leads to an imbalance favoring estrogenic effects on breast tissue.

Q: All can be seen in this patient except:

Myxedema. ***Myxedema*** - The patient's wide-eyed, **staring expression** with visible sclera above the iris (**Dalrymple sign**) and thin, curly hair are classical features of **hyperthyroidism** (Grave's disease). - Myxedema is characteristic of **severe hypothyroidism**, presenting with non-pitting edema, periorbital puffiness, and facial dullness, which are opposite to the patient's presentation. *Dalrymple sign* - This sign, characterized by **upper eyelid retraction** causing a wide-eyed stare and visible sclera above the iris, is clearly evident in the patient's image. - It is a classic ocular manifestation of **Graves' ophthalmopathy** in hyperthyroidism. *Moist warm hands* - Patients with **hyperthyroidism** typically exhibit increased metabolic activity, leading to **vasodilation** and increased sweating. - This results in the characteristic finding of **moist, warm, and often tremulous hands**. *Constipation* - **Hyperthyroidism** typically causes increased gastrointestinal motility due to elevated thyroid hormone levels. - This generally leads to **diarrhea** or more frequent bowel movements, not constipation.

Q: A specific clinical sign is characterized by spasm of hand muscles upon inflating a blood pressure cuff. What is this sign called?

Trousseau sign. ***Trousseau sign*** - This sign is characterized by the induction of **carpal spasm** (flexion of the wrist and metacarpophalangeal joints, extension of the interphalangeal joints, and adduction of the thumb) by inflating a blood pressure cuff above systolic pressure for 3-5 minutes. - It is a classic clinical sign of **hypocalcemia**, indicating increased neuromuscular irritability. *Chvostek sign* - This sign involves twitching of the **facial muscles** elicited by tapping on the facial nerve just anterior to the ear. - It is also a clinical sign of **hypocalcemia** but affects facial nerves rather than hand muscles. *Kernig sign* - This sign is a diagnostic maneuver for **meningitis** or **subarachnoid hemorrhage**. - It involves pain and resistance to extension of the knee when the patient's hip is flexed to 90 degrees. *Babinski sign* - This sign is an indicator of **upper motor neuron lesion** or damage to the **corticospinal tract**. - It involves dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is firmly stroked.

Q: What is the primary hyperaldosteronism due to an adrenal adenoma called?

Conn syndrome. ***Conn syndrome*** - Conn syndrome is specifically defined as **primary hyperaldosteronism** caused by a **benign adrenal adenoma** (aldosteronoma). - This condition leads to excessive aldosterone production, resulting in **hypertension**, **hypokalemia**, and metabolic alkalosis. *Option A* - This is a generic placeholder and does not refer to a specific medical condition. - No medical diagnosis is associated with "Option A". *Option C* - This is a generic placeholder and does not refer to a specific medical condition. - It does not describe primary hyperaldosteronism due to an adrenal adenoma. *Option D* - This is a generic placeholder and does not refer to a specific medical condition. - There is no medical condition known as "Option D".

Question 1

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?

Accepted Answer

Radioactive iodine ablation

Answer

Propylthiouracil for 6 months

Answer

Immediate thyroidectomy

Answer

Beta-blockers only

Question 2

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?

Accepted Answer

Failure to suppress GH by OGTT

Answer

Failure to suppress IGF-1 by OGTT

Answer

GH levels

Answer

IGF-1 levels

Question 3

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?

Accepted Answer

Empagliflozin

Answer

Sitagliptin

Answer

Glimepiride

Answer

Pioglitazone

Question 4

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?

Accepted Answer

3 % Saline

Answer

0.9 % Normal saline

Answer

Potassium monitoring

Answer

IV infusion insulin

Question 5

A patient presents with salt wasting, craving, hyperkalemia, metabolic acidosis, and skin pigmentation. What is the most likely diagnosis?

Accepted Answer

Addison's disease

Answer

Pheochromocytoma

Answer

Cushing's syndrome

Answer

Conn's syndrome

Question 6

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

Accepted Answer

Paget's disease of bone

Answer

Multiple myeloma

Answer

Osteosarcoma

Answer

Osteomalacia

Question 7

All are true regarding this picture of 16-year-old boy except: (Recent NEET Pattern 2016-17)

Accepted Answer

ACTH excess

Answer

Gynecomastia is defined as $>2 \mathrm{~cm}$ breast tissue

Answer

Unilateral in pubertal boys

Answer

Seen in CRF

Question 8

All can be seen in this patient except:

Accepted Answer

Myxedema

Answer

Dalrymple sign

Answer

Moist warm hands

Answer

Constipation

Question 9

A specific clinical sign is characterized by spasm of hand muscles upon inflating a blood pressure cuff. What is this sign called?

Accepted Answer

Trousseau sign

Answer

Chvostek sign

Answer

Kernig sign

Answer

Babinski sign

Question 10

What is the primary hyperaldosteronism due to an adrenal adenoma called?

Accepted Answer

Conn syndrome

Answer

Option A

Answer

Option C

Answer

Option D

Endocrinology — MCQs

Endocrinology — MCQs

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