Endocrinology — MCQs

A 14-year-old female presents with polyuria, fatigue, and fruity breath, having lost 5 kg. Her blood glucose is 450 mg/dL, pH is 7.1, bicarbonate is 12 mEq/L, and potassium is 5.8 mEq/L. The ECG shows peaked T waves and a wide QRS complex. Urine ketones are positive. What is the next step in management?

Q285

A 9-year-old boy with type 1 diabetes mellitus presents with nausea, vomiting, and abdominal pain. Physical examination reveals fruity breath and Kussmaul breathing. Laboratory results show glucose at 450 mg/dL, decreased bicarbonate, increased anion gap, and elevated ketones. What is the most appropriate immediate management?

Q286

In pediatric endocrinology, for which condition is growth hormone therapy most commonly indicated?

Q287

What is the most effective initial treatment for a child with suspected diabetic ketoacidosis?

Q288

A 12-year-old boy presents with polyuria, polydipsia, and significant weight loss. His laboratory results reveal a glucose level of 380 mg/dL, increased osmolality, and normal pH. What is the best initial management for this patient with new-onset diabetes and severe hyperglycemia?

Q289

A 6-year-old child with growth hormone deficiency is not responding adequately to therapy. Analyze the situation and determine the most likely cause.

Q290

A 10-year-old with growth hormone deficiency on recombinant human growth hormone for one year shows no increase in growth velocity, with compliance confirmed. What is the next best step?

Endocrinology Indian Medical PG Practice Questions and MCQs

Question 281: A 5-year-old girl presents with difficulty breathing. On examination of the oral cavity, a 3 cm mass is found in the midline on the posterior aspect of the tongue. The most likely diagnosis is:

A. Foreign body stuck to the tongue
B. Lingual tonsil
C. Dermoid
D. Lingual thyroid (Correct Answer)

Explanation: ***Lingual thyroid*** - A lingual thyroid is **ectopic thyroid tissue** located at the base of the tongue, often presenting as a **midline mass**. - Its presence can lead to **obstruction of the airway** or difficulty swallowing, explaining the patient's difficulty breathing. *Foreign body stuck to the tongue* - While a foreign body could cause obstruction, it would typically present with a **sudden onset** and usually has a clear history of ingestion. - A 3 cm mass in the midline is more consistent with a **developmental anomaly** rather than an acutely lodged object. *Lingual tonsil* - The lingual tonsils are normal lymphatic tissue located at the **base of the tongue**; however, they are usually **bilateral and diffuse**, not presenting as a single 3 cm midline mass. - Significant enlargement of a single lingual tonsil to this size causing respiratory distress is **uncommon** without other inflammatory signs. *Dermoid* - A dermoid cyst can appear as a **midline mass** in the oral cavity, but typically it presents as a **soft, doughy, non-transilluminating swelling**. - While it can cause obstructive symptoms if large, a lingual thyroid is a more specific diagnosis for a **vascularized mass** at the base of the tongue in this clinical context.

Question 282: At what age is delayed puberty diagnosed in girls if they have not developed any secondary sexual characteristics?

A. 13 years (Correct Answer)
B. 18 years
C. 12 years
D. 16 years

Explanation: ***Correct: 13 years*** - In girls, **delayed puberty** is diagnosed when there are no signs of **breast development (thelarche) by age 13 years** - This represents the upper limit of normal for the onset of secondary sexual characteristics in girls - Absence of any pubertal development by this age warrants evaluation for underlying causes (e.g., hypogonadism, constitutional delay, chronic illness) - Based on **Tanner staging**, breast development typically begins between ages 8-13 years *Incorrect: 18 years* - This age is well beyond the diagnostic threshold for delayed puberty - By 18 years, puberty should be complete in normal girls - Waiting until this age would delay diagnosis and treatment of potentially reversible causes *Incorrect: 12 years* - 12 years is still within the **normal range for onset of puberty** in girls - Many girls normally begin pubertal development at or after age 12 - Diagnosing delayed puberty at this age would be premature and lead to unnecessary investigations *Incorrect: 16 years* - 16 years is the diagnostic age specifically for **absence of menarche** (primary amenorrhea), not for absence of all secondary sexual characteristics - If secondary sexual characteristics are absent by age 16, this indicates severe delay that should have been investigated years earlier (by age 13)

Question 283: A 6-month-old infant shows delayed social smile, poor head control, and hypotonia. TSH is elevated, and T4 is low. What is the most likely diagnosis?

A. Down syndrome
B. Prader-Willi syndrome
C. Cerebral palsy
D. Congenital hypothyroidism (Correct Answer)

Explanation: ***Congenital hypothyroidism*** - The combination of **developmental delay** (delayed social smile, poor head control), **hypotonia**, and **abnormal thyroid function tests** (elevated TSH, low T4) is highly suggestive of congenital hypothyroidism. - Early diagnosis and treatment are crucial to prevent **intellectual disability** and severe developmental impairments. *Down syndrome* - While infants with Down syndrome often present with **hypotonia** and developmental delay, the characteristic **facial features** (e.g., epicanthal folds, upward slanting palpebral fissures) and a **normal thyroid profile** would typically differentiate it. - Down syndrome is a **chromosomal disorder** (trisomy 21) not primarily characterized by thyroid dysfunction, although **hypothyroidism** can be a co-occurrence. *Prader-Willi syndrome* - This syndrome is characterized by **severe hypotonia** and feeding difficulties in infancy, followed by childhood-onset **hyperphagia** and obesity. - It is a **genetic disorder** affecting chromosome 15, and while developmental delay and hypotonia are present, routine thyroid function tests are usually normal. *Cerebral palsy* - Cerebral palsy is a group of **motor disorders** caused by non-progressive brain damage that occurs during fetal development or early in life, leading to **abnormal muscle tone**, posture, and movement. - While it can manifest with hypotonia and developmental delay, cerebral palsy is not associated with **elevated TSH and low T4**.

Question 284: A 14-year-old female presents with polyuria, fatigue, and fruity breath, having lost 5 kg. Her blood glucose is 450 mg/dL, pH is 7.1, bicarbonate is 12 mEq/L, and potassium is 5.8 mEq/L. The ECG shows peaked T waves and a wide QRS complex. Urine ketones are positive. What is the next step in management?

A. Sodium bicarbonate infusion
B. Potassium-free fluids + insulin drip (Correct Answer)
C. IV regular insulin bolus
D. Calcium gluconate IV push

Explanation: ***Potassium-free fluids + insulin drip*** - The patient presents with **diabetic ketoacidosis (DKA)** (hyperglycemia, acidosis, ketones) which is the primary condition requiring immediate management. - **IV fluid resuscitation** with 0.9% normal saline is the **first priority** in DKA to restore intravascular volume, improve tissue perfusion, and begin diluting glucose and ketones. - **Continuous insulin infusion** (0.05-0.1 units/kg/hr in pediatrics, **NOT bolus** due to cerebral edema risk) is essential to stop ketogenesis, lower blood glucose, and correct acidosis. - The hyperkalemia (5.8 mEq/L) in DKA is **pseudo-hyperkalemia** due to extracellular shift from acidosis and insulin deficiency; **total body potassium is actually depleted**. Insulin therapy will drive potassium intracellularly, often requiring potassium supplementation once levels drop below 5.0 mEq/L. - Starting with **potassium-free fluids** is appropriate initially, with potassium added to subsequent fluids based on monitoring. *Calcium gluconate IV push* - While calcium gluconate stabilizes cardiac membranes in **primary hyperkalemia** (e.g., renal failure), it is **not the priority** in DKA-associated hyperkalemia. - The ECG changes will resolve with appropriate DKA management as insulin and fluids correct the potassium shift. - Calcium does not address the underlying **life-threatening DKA**. *Sodium bicarbonate infusion* - **Not routinely recommended** in DKA management, especially in pediatrics, as it may worsen hypokalemia, cause paradoxical CNS acidosis, and increase cerebral edema risk. - Insulin therapy and fluid resuscitation will correct the acidosis physiologically. - Reserved only for severe acidosis (pH <6.9) with hemodynamic instability, which is not the case here. *IV regular insulin bolus* - In **pediatric DKA**, insulin **bolus is contraindicated** as it increases the risk of **cerebral edema**, a major cause of mortality. - The standard approach is **continuous low-dose insulin infusion** after initial fluid resuscitation (1-2 hours). - Additionally, this option doesn't address the critical need for **fluid resuscitation** first.

Question 285: A 9-year-old boy with type 1 diabetes mellitus presents with nausea, vomiting, and abdominal pain. Physical examination reveals fruity breath and Kussmaul breathing. Laboratory results show glucose at 450 mg/dL, decreased bicarbonate, increased anion gap, and elevated ketones. What is the most appropriate immediate management?

A. IV insulin, IV fluids, electrolyte management (Correct Answer)
B. Subcutaneous insulin, oral hydration
C. Bicarbonate therapy, IV fluids, ICU admission
D. Close monitoring, oral hydration

Explanation: ***IV insulin, IV fluids, electrolyte management*** - The patient's presentation of **nausea, vomiting, abdominal pain, fruity breath, Kussmaul breathing**, and laboratory findings of **hyperglycemia (450 mg/dL), metabolic acidosis (decreased bicarbonate, increased anion gap), and elevated ketones** are classic for **Diabetic Ketoacidosis (DKA)**. - DKA management requires: **(1) IV fluids** (0.9% normal saline) to correct severe dehydration and restore perfusion, **(2) IV insulin** (regular insulin infusion at 0.05-0.1 units/kg/hr) to lower blood glucose and reverse ketosis, and **(3) electrolyte management**, especially **potassium replacement** (as insulin drives potassium intracellularly, risking hypokalemia and cardiac arrhythmias). - This triad directly addresses the pathophysiology: dehydration, insulin deficiency, and electrolyte imbalances. *Subcutaneous insulin, oral hydration* - **Subcutaneous insulin** is inappropriate for DKA as it has slower onset and unreliable absorption in severely dehydrated patients; **IV insulin** is required for rapid, predictable action. - **Oral hydration** is insufficient for severe dehydration (typically 5-10% dehydration in DKA) and impractical due to vomiting and decreased consciousness risk. *Bicarbonate therapy, IV fluids, ICU admission* - **Bicarbonate therapy** is generally **not recommended** in pediatric DKA (even with severe acidosis) as it increases risk of **cerebral edema**, hypokalemia, and paradoxical CNS acidosis. Only considered if pH < 6.9 with cardiac dysfunction. - While IV fluids and ICU monitoring are appropriate, bicarbonate is not standard therapy and can be harmful. *Close monitoring, oral hydration* - This is dangerously inadequate for DKA, which is a **life-threatening emergency** requiring aggressive intervention within the first hour. - Without prompt treatment, DKA can progress to cerebral edema, cerebrovascular accidents, and death; mortality is 0.15-0.3% even with treatment.

Question 286: In pediatric endocrinology, for which condition is growth hormone therapy most commonly indicated?

A. Idiopathic short stature
B. Growth hormone deficiency (Correct Answer)
C. Turner syndrome
D. Constitutional delay of growth and puberty

Explanation: ***Growth hormone deficiency*** - **Growth hormone (GH) deficiency** is the primary and most direct indication for GH therapy, as it replaces the missing hormone essential for normal growth. - Diagnosis is made by **stimulation tests** which show insufficient GH secretion, leading to short stature. *Idiopathic short stature* - While GH therapy can be used for **idiopathic short stature** (ISS), it is typically reserved for severe cases where the child's height is significantly below the population norm and there are no identifiable medical causes. - The response to GH therapy in ISS is often less pronounced and more variable than in true GH deficiency. *Turner syndrome* - **Turner syndrome** is a chromosomal disorder (45,X) that causes short stature, for which GH therapy is an approved treatment. - However, the primary indication for GH is **GH deficiency** itself, making it a more fundamental and common reason for therapy. *Constitutional delay of growth and puberty* - **Constitutional delay of growth and puberty** is a variation of normal development where growth and puberty occur later than average. - GH therapy is generally not indicated for this condition, as children eventually reach their normal adult height without intervention, although sometimes **testosterone** or **estrogen** is used to induce puberty.

Question 287: What is the most effective initial treatment for a child with suspected diabetic ketoacidosis?

A. Subcutaneous insulin
B. Oral rehydration
C. Intravenous fluids and insulin (Correct Answer)
D. Dialysis

Explanation: ***Intravenous fluids and insulin*** - **Intravenous fluids** are crucial to correct dehydration and improve renal perfusion, while **insulin** is necessary to reverse the metabolic acidosis and hyperglycemia. - This combined approach rapidly addresses the life-threatening metabolic derangements of **DKA**. *Subcutaneous insulin* - **Subcutaneous insulin** has a slower absorption rate and is not appropriate for the acute management of **DKA**, where rapid action is needed. - It would not sufficiently address the severe **dehydration** and **acidosis** seen in DKA. *Oral rehydration* - Children with **DKA** are often nauseated or vomiting and have impaired consciousness, making **oral rehydration** unreliable and often impossible. - It would not be fast enough to correct severe **dehydration** and metabolic disturbances. *Dialysis* - **Dialysis** is an extreme measure used for severe complications like **renal failure** or certain intoxications, not for the initial management of **DKA**. - There is no indication for **dialysis** in this scenario unless severe **acute kidney injury** unmanageable by fluid resuscitation is present.

Question 288: A 12-year-old boy presents with polyuria, polydipsia, and significant weight loss. His laboratory results reveal a glucose level of 380 mg/dL, increased osmolality, and normal pH. What is the best initial management for this patient with new-onset diabetes and severe hyperglycemia?

A. Subcutaneous insulin + close monitoring for acidosis (Correct Answer)
B. IV insulin + fluids
C. Oral antidiabetic agents with lifestyle modification
D. IV fluids and subcutaneous insulin

Explanation: ***Subcutaneous insulin + close monitoring for acidosis*** - This patient presents with **new-onset Type 1 Diabetes** with severe hyperglycemia (glucose 380 mg/dL) but **normal pH**, indicating the absence of diabetic ketoacidosis (DKA). - With **normal pH and no acidosis**, the appropriate initial management is **subcutaneous rapid-acting insulin** (not IV insulin), along with IV fluids for dehydration. - **Close monitoring for acidosis** is essential because these patients can rapidly progress to DKA, requiring escalation to IV insulin if pH drops below 7.3 or bicarbonate falls. - This approach provides effective glucose control while avoiding the risks and complexity of IV insulin infusion when not yet indicated. *IV insulin + fluids* - **IV insulin** is specifically indicated for **diabetic ketoacidosis (DKA)** with pH <7.3 or **hyperglycemic hyperosmolar state (HHS)**. - Since this patient has **normal pH**, they do not meet criteria for IV insulin therapy, which is reserved for critical metabolic decompensation. - Starting IV insulin unnecessarily exposes the patient to higher risk of **hypoglycemia** and requires intensive care monitoring that is not yet warranted. *Oral antidiabetic agents with lifestyle modification* - This approach is completely inappropriate for **new-onset Type 1 Diabetes in a child** presenting with severe hyperglycemia and classic symptoms. - Children with these features have **absolute insulin deficiency** and require exogenous insulin immediately; oral agents are ineffective in Type 1 Diabetes. - Delaying insulin therapy could lead to rapid progression to **life-threatening DKA**. *IV fluids and subcutaneous insulin* - While this combination is close to correct, the phrasing suggests both are given simultaneously as initial management. - The best answer emphasizes the critical importance of **close monitoring for acidosis**, which is the key safety consideration in managing severe hyperglycemia with normal pH. - Without explicit mention of monitoring for DKA progression, this option is less complete than the correct answer.

Question 289: A 6-year-old child with growth hormone deficiency is not responding adequately to therapy. Analyze the situation and determine the most likely cause.

A. Concomitant hypothyroidism (Correct Answer)
B. Incorrect diagnosis
C. Poor adherence to treatment
D. Insufficient dosing

Explanation: ***Concomitant hypothyroidism*** - **Thyroid hormones** are essential for normal growth and the action of **growth hormone (GH)**. If untreated, **hypothyroidism** can significantly impair growth, even in the presence of adequate GH replacement. - Therefore, in a child with **growth hormone deficiency (GHD)** not responding to therapy, concurrent **hypothyroidism** should always be ruled out and treated. *Poor adherence to treatment* - While a common cause of treatment failure in chronic conditions, the question states the child "is not responding adequately to therapy," implying the therapy is being administered. - This would typically manifest as a lack of response over time, but other physiological causes should be investigated first. *Insufficient dosing* - This is a plausible cause of suboptimal response and would be considered during dose adjustments. - However, **endocrine conditions** like **hypothyroidism** can block the effectiveness of GH even with sufficient dosing. *Incorrect diagnosis* - The question states the child has "growth hormone deficiency," implying this diagnosis has already been established. - While a re-evaluation of the diagnosis may be necessary if other causes are ruled out, it is not the most likely initial cause for lack of response when therapy is being given.

Question 290: A 10-year-old with growth hormone deficiency on recombinant human growth hormone for one year shows no increase in growth velocity, with compliance confirmed. What is the next best step?

A. Increase rhGH dose
B. Measure serum IGF-1 (Correct Answer)
C. Perform insulin tolerance test
D. Test for anti-GH neutralizing Ab

Explanation: ***Measure serum IGF-1*** - Measuring **serum IGF-1 (Insulin-like Growth Factor 1)** is crucial to assess the body's response to recombinant human growth hormone (rhGH) and determine if the current dosage is sufficient. Growth velocity is primarily mediated by IGF-1. - If **IGF-1 levels are low** despite rhGH administration, it suggests either an inadequate dose or a problem with IGF-1 production or action, requiring further investigation or dose adjustment. *Increase rhGH dose* - Increasing the rhGH dose without knowing the **current IGF-1 levels** or growth velocity response could lead to over-treatment or may not address underlying issues if IGF-1 production is already maximal. - While dose adjustment might be needed, it should be guided by **biochemical markers** and clinical response, not done blindly. *Perform insulin tolerance test* - An **insulin tolerance test (ITT)** is a gold standard for diagnosing growth hormone deficiency by stimulating GH release, but the patient is already diagnosed and on treatment. - Performing an ITT in a patient already on rhGH would be **redundant** and potentially dangerous given the risk of hypoglycemia. *Test for anti-GH neutralizing Ab* - **Antibody formation against rhGH** is a rare phenomenon that can lead to treatment failure but is not typically the first step when assessing a lack of growth response. - This test is usually considered in cases of **absolute non-response to escalating doses** of rhGH, after optimizing the dose based on IGF-1 levels.

Practice by Chapter

Disorders of Growth

Practice Questions

Thyroid Disorders

Practice Questions

Disorders of Puberty

Practice Questions

Adrenal Disorders

Practice Questions

Diabetes Mellitus in Children

Practice Questions

Disorders of Calcium and Phosphate Metabolism

Practice Questions

Disorders of Sexual Development

Practice Questions

Hypoglycemia

Practice Questions

Obesity and Metabolic Syndrome

Practice Questions

Pituitary Disorders

Practice Questions

Multiple Endocrine Neoplasia Syndromes

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Endocrine Emergencies

Practice Questions

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