1
Q
occurs most often in postpartum women; it usually presents with hyperprolactinemia and MRI evidence of a prominent pituitary mass that often resembles an adenoma, with mildly elevated PRL levels
A
Lymphocytic Hypophysitis
Tx: often resolves after several months of glucocorticoid treatment, and pituitary function may be restored
2
Q
may occur spontaneously in a preexisting pituitary adenoma; postpartum (Sheehan’s syndrome); or in association with diabetes, hypertension, sickle cell anemia, or acute shock
Pituitary computed tomography (CT) or MRI may reveal signs of intratumoral or sellar hemorrhage, with pituitary stalk deviation and compression of pituitary tissue
A
Pituitary apoplexy
3
Q
Tx Pituitary apoplexy
-No visual loss/ consciousness
-Significant or progressive visual loss, CN palsy or LOC
A
-High dose glucocorticoids
-Urgent surgical decompression
4
Q
partial or apparently totally empty sella is often an incidental MRI finding and may sometimes be associated with intracranial hypertension. These patients usually have normal pituitary function
A
Empty sella
5
Q
Skeletal maturation is best evaluated by measuring a radiologic bone age, which is based mainly on _______
A
degree of wrist bone growth plate fusion
6
Q
AGHD is defined by
A
a peak GH response to hypoglycemia of <3 ug/L
7
Q
In contrast to primary adrenal failure, hypocortisolism associated with pituitary failure usually is NOT accompanied by _____ or _______
A
hyperpigmentation or mineralocorticoid deficiency
8
Q
What is the most common presenting feature of adult hypopituitarism even when other pituitary hormones are also deficient?
A
Hypogonadism
9
Q
Sellar mass +
Bony hyperostosis?
Calcifications and hyperdense?
Hyperdense on T2-weighted images
A
Meningiomas
Craniopharyngiomas
Gliomas
10
Q
benign, suprasellar cystic masses that present with headaches, visual field deficits, and variable degrees of hypopituitarism. They are derived from Rathke’s pouch
often large, cystic, and locally invasive. Many are partially calcified, exhibiting a characteristic appearance on skull x-ray and CT images
A
Craniopharyngioma
11
Q
the most common cause of pituitary hormone hypersecretion and hyposecretion syndromes in adults
A
Pituitary adenomas
12
Q
is the most common pituitary hormone hypersecretion syndrome in both men and women
A
Hyperprolactinemia
PRLsecreting pituitary adenomas (prolactinomas) are the most common cause of PRL levels >200 ug/L
13
Q
Galactorrhea, the inappropriate discharge of milk-containing fluid from the breast, is considered abnormal if it persists
A
longer than 6 months after childbirth or discontinuation of breast-feeding
14
Q
Tx Prolactinoma
-patients are asymptomatic and fertility is not desired
-Sx microadenoma
A
-should be monitored by regular serial PRL measurements and MRI scans
-control of hyperprolactinemia, reduction of tumor size, restoration of menses and fertility, and resolution of galactorrhea
15
Q
mainstay of therapy for patients with micro- or macroprolactinomas
A
Oral dopamine agonists (cabergoline and bromocriotine)
- In patients with microadenomas who have achieved normoprolactinemia and significant reduction of tumor mass, the dopamine agonist may be withdrawn after 2 years
16
Q
dopamine receptor agonist that suppresses PRL secretion. Because it is short-acting, the drug is preferred when pregnancy is desired
A
B for buntis
Bromocriptine
17
Q
The most important, if not the only, physiologic action of AVP is to
A
reduce water excretion by promoting concentration of urine
18
Q
What is a better measure of thyroid function in the months following radioiodine treatment
A
Unbound T4
19
Q
If there is no residual thyroid function, what is the daily replacement dose of LT4?
A
is usually 1.6 ug/kg body weight (typically 100–150 ug), ideally taken at least 30 min before breakfast
20
Q
Dose of LT4 for Adult patients under 60 years old without evidence of heart
A
50-100 ug of LT4 daily
21
Q
The dose is adjusted on the basis of____ levels, with the goal of treatment being a normal ___, ideally in the lower half of the reference range
A
TSH
Measured after 2 months
22
Q
In hypothyroidism, Patients may not experience full relief from symptoms until __________ after normal TSH levels are restored
A
3–6 months
LT4 dosage is made in 12.5- or 25 ug increments if the TSH is high
Once full replacement is achieved and TSH levels are stable, follow-up measurement of TSH is recommended at annual intervals
23
Q
True or False
Because T4 has a long half-life (7 days), patients who miss a dose can be advised to take two doses of the skipped tablets at once
A
True
24
Q
Target in pregnant patients with hypothyroidism
A
TSH in the normal range but <2.5 mIU/L
Because of the known increase in thyroid hormone requirements during pregnancy in hypothyroid women
Women should increase LT4 from once-daily dosing to nine doses per week as soon as pregnancy is confirmed to anticipate this change
25
In the elderly, especially patients with known coronary artery disease, the starting dose of LT4 is ____ with similar increments every 2–3 months until TSH is normalized
12.5–25 ug/d
26
Tx for myxedema coma
LT4 single IV bolus of 200–400 ug loading dose, followed by a daily oral dose of 1.6 ug/kg per d, reduced by 25% if administered IV
initial loading dose of 5–20 ;g liothyronine should be followed by 2.5–10 ;g every 8 h
External warming if T<30 oC
Hydrocortisone 50mg IV q6
27
Tx for myxedema coma
LT4 single IV bolus of 200–400 ug loading dose, followed by a daily oral dose of 1.6 ug/kg per d, reduced by 25% if administered IV
initial loading dose of 5–20 ;g liothyronine should be followed by 2.5–10 ;g every 8 h
External warming if T<30 oC
Hydrocortisone 50mg IV q6
28
The “NO SPECS” scoring system to evaluate ophthalmopathy is an acronym derived from the following changes
0 = No signs or symptoms
1 = Only signs (lid retraction or lag), no symptoms
2 = Soft tissue involvement (periorbital edema)
3 = Proptosis (>22 mm)
4 = Extraocular muscle involvement (diplopia)
5 = Corneal involvement
6 = Sight loss
29
form of clubbing found in <1% of patients with Graves’ disease (Fig. 384-1C). It is so strongly associated with thyroid dermopathy that an alternative cause of clubbing should be sought in a Graves’ patient without coincident skin and orbital involvement
Thyroid acropachy
30
because of its rare association with hepatotoxicity, propylthiouracil should be limited to the first trimester and then maternal therapy should be converted to methimazole (or carbimazole) at a ratio of
ratio of 15–20 mg of propylthiouracil to 1 mg of methimazole
31
Tx for thyrotoxic crisis
PTU (500–1000 mg loading dose and 250 mg every 4 h) should be given orally or by nasogastric tube or per rectum
SSKI 5 drops q6
Propanolol 60–80 mg PO every 4 h, or 2 mg IV every 4 h
hydrocortisone 300 mg IV bolus, then 100 mg every 8 h
32
is rare and due to suppurative infection of the thyroid. In children and young adults, the most common cause is the presence of a piriform sinus
Acute thyroiditis
33
The patient usually presents with a painful and enlarged thyroid, sometimes accompanied by fever. There may be features of thyrotoxicosis or hypothyroidism, depending on the phase of the illness. Malaise and symptoms of an upper respiratory tract infection may precede the thyroid-related features by several weeks
Tx?
Subacute/ de Quervain’s thyroiditis
Relatively large doses of aspirin (e.g., 600 mg every 4–6 h) or nonsteroidal anti-inflammatory drugs (NSAIDs
34
Amiodarone induced thyrotoxicosis
associated with an underlying thyroid abnormality (preclinical Graves’ disease or nodular goiter). Thyroid hormone synthesis becomes excessive as a result of increased iodine exposure (JodBasedow phenomenon)
Type 1 AIT
Tx Potassium perchlorate
35
Amiodarone induced thyrotoxicosis
no intrinsic thyroid abnormalities and is the result of drug-induced lysosomal activation leading to destructive thyroiditis with histiocyte accumulation in the thyroid
Type 2 AIT
Tx: Glucocorticoids have modest effect
36
Obesity Diet therapy
Goal calorie deficit
calorie deficit of 500–750 kcal/d compared with the patient’s habitual diet. Alternatively, a diet of 1200–1500 kcal/d for women and 1500–1800 kcal/d for men (adjusted for the individual’s body weight) can be prescribed. This reduction is consistent with a goal of losing ~1–2 lb/week
37
Obesity Physical activity therapy
2018 physical activity guidelines for Americans recommendation
adults should engage in 150 min of moderate-intensity or 75 min a week of vigorous-intensity aerobic physical activity per week, preferably spread throughout the week
38
restrictive-malabsorptive procedures carry an increased risk for micronutrient deficiencies of what vitamins?
B12, iron, folate, calcium, and vitamin
39
Glucose intolerance developing during the what trimester of pregnancy is classified as gestational diabetes mellitus (GDM)?
Second or third trimester
ADA recommends that diabetes diagnosed within the first trimester be classified as preexisting pregestational diabetes rather than GDM
** women with a history of GDM undergo lifelong screening for the development of diabetes or prediabetes at least every 3 years
40
development of a type 2 diabetes phenotype before puberty and a type 2 diabetes phenotype in very lean individuals
Atypical diabetes
41
The current criteria for the diagnosis of DM emphasize what tests as the most reliable and convenient tests for identifying DM in asymptomatic individuals
HbA1c and the FPG
42
For other individuals not overweight/obese, no history of GDM, IFG or IGT, when do you screen for type 2 DM?
At age 45 every 3 years
43
Insulin secretion phase that among the earliest detectable abnormalities during the progression of both T1DM and T2DM
Impaired rapid first phase insulin responses
44
Stages of Type 1 DM
A. two or more islet cell autoantibodies but the maintenance of normoglycemia
B. continued autoimmunity and the development of dysglycemia
C. development of hyperglycemia that exceeds the diagnostic criteria for the diagnosis of diabetes
D. First 1-2 yrs after onset of DM, glycemic control is achieved with modest doses of insulin or, rarely, insulin is not needed
Stage 1
Stage 2
Stage 3
Honeymoon phase
45
What mechanism predominantly accounts for increased FPG levels?
Increased hepatic glucose output
46
What mechanism results in postprandial hyperglycemia?
Decreased peripheral glucose utilization
47
Syndrome of insulin resistance
A. affects young women more severely and is characterized by severe hyperinsulinemia, obesity, and features of hyperandrogenism
B. affects middle-aged women and is characterized by severe hyperinsulinemia, features of hyperandrogenism, and autoimmune disorders
Type A
Type B
48
Should be considered in individuals with both IFG and IGT who are at very high risk for progression to diabetes (ageC<60 years, BMI =35 kg/m2, and women with a history of GDM
Metformin
** Individuals with IFG, IGT, or an HbA1c of 5.7–6.4% should be monitored annually
49
Mutations in MODY
MODY 1
MODY 3
MODY 5
MODY 1- HNF 4a
MODY 3- HNF 1a
MODY 5- HNF 1B
50
These individuals have a progressive decline in glycemic control but may respond to sulfonylureas
MODY 3 (HNF 1a)
51
have progressive impairment of insulin secretion and hepatic insulin resistance, and require insulin treatment with minimal response to sulfonylureas
MODY 5 (HNF 1B)
52
the result of mutations in the glucokinase gene, have mild-to-moderate, but stable hyperglycemia that does not respond to oral hypoglycemic agents, and otherwise does not require treatment
MODY 2
53
the most common cause of pancreatic agenesis
Mutations in the transcription factor GATA6
54
Complications related to chronic hyperglycemia typically begin to appear during the ___ decade of hyperglycemia
second decade
55
The ADA recommends annual screening for distal symmetric polyneuropathy beginning with the initial diagnosis of diabetes and annual screening for autonomic neuropathy
For type 1 DM?
Type 2 DM?
5 years after diagnosis of type 1 DM and at the time of diagnosis of type 2 DM
56
Symptoms of diabetes usually resolve when the plasma glucose is
<11.1 mmol/L (200 mg/dL
57
clinically significant hypoglycemia
<3.0 mmol/L or 54 mg/dL
58
DM goals
Weight loss
Activity
5-10% weight loss
ADA recommends 150 min/week (distributed over at least 3 days) of moderate aerobic physical activity with no gaps longer than 2 days
59
To avoid exercise-related hyper- or hypoglycemia, individuals with type 1 DM should
(1) monitor blood glucose before, during, and after exercise;
(2) delay exercise if blood glucose is >14 mmol/L (250 mg/ dL) and ketones are present;
(3) if the blood glucose is <5.0 mmol/L (90 mg/dL), ingest carbohydrate before exercising;
(4) monitor glucose during exercise and ingest carbohydrate as needed to prevent hypoglycemia;
(5) decrease insulin doses (based on previous experience) before and after exercise and inject insulin into a nonexercising area; and
(6) learn individual glucose responses to different types of exercise
60
is a relative contraindication to vigorous exercise, because this may lead to vitreous hemorrhage or retinal detachment
Untreated proliferative retinopathy
61
SGLT2i should not be started in CKD stage? And not used in stage?
Do not start in eGFR 45 Stage 3b
Do not use in eGFR 30 stage 4
62
Why is bedtime insulin more effective than single dose of morning insulin?
Because fasting hyperglycemia and increased hepatic glucose production are prominent features of type 2 DM
63
Choice of initial glucose-lowering agent
Mild hyperglycemia 126-199
Moderate 200-250
Severe >250
126-199mg/dl single oral
200-250 mg/dl combination oral or insulin
>250 mg/dl insulin
64
What does A normal serum sodium in the setting of DKA indicate?
a more profound water deficit
65
In pregnant patients, when should screening for glucose intolerance in women not known to have diabetes be done?
between weeks 24 and 28 of pregnancy
66
Oral glucose-lowering agents are not approved for use during pregnancy, but studies using which drugs have shown efficacy and have not found toxicity
metformin or glyburide
67
What is the mainstay of treatment in patients with micro or macroprolactinoma?
Oral dopamine agonists (cabergoline or bromocriptine)
68
What is the mainstay of therapy for patients with micro or macroprolactinomas?
Oral dopamine agonists (cabergoline/bromocriptine)
69
In patients with microadenomas who achieve normoprolactinemia with cabergoline, when is it appropriate to withdraw therapy?
2 years
70
These features are more supportive of ectopic ACTH secretionthan pituitary dependent Cushing’s syndrome
features of hypercortisolism associated with skin hyperpigmentation and severe myopathy suggests an ectopic tumor source of ACTH. Hypertension, hypokalemic alkalosis, glucose intolerance, and edema are also more pronounced in these patients. Serum potassium levels <3.3 mmol/L
71
Hypercortisolism tx
an SRL with high affinity for SST5 > SST2 receptor subtypes, may control hypercortisolemia in a subset of patients with ACTH-secreting pituitary tumors when surgery is not an option or has not been successful
Pasireotide LAR
72
an oral 11β-hydroxylase inhibitor that blocks adrenal gland cortisol biosynthesis, normalized 24-h UFC in 86% of patients
Osilodrostat
73
a glucocorticoid receptor antagonist, blocks peripheral cortisol action and is approved to treat hyperglycemia in Cushing’s disease. Because the drug does not target the pituitary tumor, both ACTH and cortisol levels remain elevated
Mifepristone
74
inhibits 11β-hydroxylase activity and normalizes plasma cortisol in up to 75% of patients
Metyrapone
75
Which genetic mutation is most commonly associated with autosomal dominant central diabetes insipidus?
Mutation in AVP neurophysin II gene
76
What approach reliably differentiates between partial pituitary DI and primary polydipsia when plasma osmolarity and serum sodium are within normal limits?
Plasma AVP level after 3% saline infusion
77
What is the most frequent adverse event and cause of treatment discontinuation in testosterone trials?
Erythrocytosis
If hct rises above 54%, testosterone therapy should be stopped until hct has fallen to <50%
78
A patient undergoing testosterone replacement has a baseline PSA of 1.2 ng/mL. After 5 months, PSA increases to 2.9 ng/mL. What is the most appropriate next step?
A. Refer for urologic evaluation
B. Continue testosterone replacement as this represents non-significant increase
C. Check testosterone, FSH, LH
D. None of the above
A. Refer for urologic evaluation
Increase in PSA > 1.4 ng/ml in any 1 year after starting testosterone therapy should lead to urologic eval
79
What are absolute contraindications to systemic postmenopausal therapy?
Breast, endometrial or other estrogen dependent cancers
Cardiovascular disease
Active liver disease
Undiagnosed vaginal bleeding
80
What are parathyroid related causes of hypercalcemia?
Primary hyperparathyroidism
Lithium therapy
Familial hypocalciuric hypercalcemia
81
What are causes of hypercalcemia associated with high bone turnover?
Hyperthyroidism
Immobilization
Thiazides
Vit A intoxication
Fat necrosis
82
Interventions with demonstrated efficacy in diabetic foot ulcers or wounds include the following
(1) off-loading, (2) debridement, (3) wound dressings, (4) appropriate use of antibiotics, (5) revascularization, and (6) limited amputation
83
Anterior neck mass with Low T4 with normal TSH and T3, low urinary iodine level (<50 ug/L)
Iodine deficiency
84
If the thyroid adenoma is composed of oncocytic follicular cells arranged in a follicular pattern
Hürthle cell adenoma
85
Characteristic cytologic features of Papillary thyroid cancer
large, clear nuclei with powdery chromatin (described as an “orphan Annie eye” appearance) with nuclear grooves and prominent nucleoli
86
For well differentiated thyroid CA, what is the initial surgery of choice for tumors
>1 cm and <4 cm?
>4 cm?
the initial surgical procedure may be either a unilateral (lobectomy) or bilateral (near-total thyroidectomy) procedure for patients with intrathyroidal cancers >1 cm and <4 cm (T1b and T2Ctumors) in the absence of metastatic disease
near-total thyroidectomy is appropriate for tumors >4 cm or in the presence of metastases or clinical evidence of extrathyroidal invasion
87
TSH supression in thyroid CA
What is the TSH level fir
Low risk of recurrence?
Intermediate risk?
High risk?
low risk of recurrence, TSH should be maintained in the lower normal limit (0.5–2.0CmIU/L).
For patients either at intermediate or high risk of recurrence, TSH levels should be kept to 0.1–0.5 mIU/L and <0.1 mIU/L
88
sensitive marker of residual/recurrent thyroid cancer after ablation of the residual postsurgical thyroid tissue
Serum thyroglobulin
* a neck ultrasound should be performed about 6 months after thyroid ablation
89
What Calcium values of are frequent with carcinoma and may alert the surgeon to remove the abnormal gland with care to avoid capsular rupture
3.5–3.7 mmol/L (14–15 mg/dL)
90
Whatis The distinctive bone manifestation of hyperparathyroidism
Osteitis fibrosa cystic
* pathognomonic features are an increase in the giant multinucleated osteoclasts in scalloped areas on the surface of the bone (Howship’s lacunae) and a replacement of the normal cellular and marrow elements by fibrous tissue
91
A 62-year-old woman underwent total thyroidectomy for a 3.8 cm encapsulated follicular thyroid carcinoma. Histopathology shows capsular penetration with limited vascular invasion, but no evidence of distant metastases. Postoperative recovery is uneventful. Which is a poor prognostic factor in this patient?
a. Tumor size >3 cm
b. Absence of marked vascular invasion
c. Age >55
d. Absence of metastasis
C. Age >55
HPIM 385, 2951
Mortality rates associated with angioinvasive FTC are less favorable than for PTC, in part because a larger proportion of patients present with stage IV disease. Poor prognostic features include distant metastases, age >55 years, primary tumor size >4 cm, and the presence of marked vascular invasion.
92
What is the most common lymphoma type that occurs in the background of Hashimoto's thyroiditis?
a. Hodgkin's lymphoma
b. Burkitt lymphoma
c. Diffuse large B cell lymphoma
d. Follicular lymphoma
C. Diffuse large B cell lymphoma
HPIM 385 p2953
Lymphoma in the thyroid gland often arises
in the background of Hashimoto’s thyroiditis. A rapidly expanding thyroid mass suggests the possibility of this diagnosis. Diffuse large-cell lymphoma is the most common type in the thyroid.
93
A 28-year-old woman at 10 weeks of gestation was seen at the OBGYN High Risk Clinic. She presents with episodic headaches, palpitations, and profuse sweating for the past month. She has had repeated episodes of severe hypertension (up to 200/110 mmHg) alternating with normal blood pressures. On exam during one such episode, she is tremulous with HR 120 bpm. Fetal heart tones are normal. Due to consideration of pre-eclampsia and pre-term labor, she was then admitted by the Perinatology service. Workup for pre-eclampsia showed normal urine protein, normal liver and platelet counts. She is referred to the IM service for workup of secondary hypertension. Plasma-free metanephrines are markedly elevated, and abdominal MRI reveals a 4 cm left adrenal mass. What is the best next step in management?
a. Immediate adrenalectomy regardless of gestational age to remove the catecholamine-secreting tumor.
b. Continue pregnancy to term with only medical alpha-adrenergic blockade, deferring surgery until postpartum.
c. Perform adrenalectomy during the second trimester (approximately 12–24 weeks gestation).
d. Initiate beta-blocker therapy alone and plan surgical intervention after delivery.
C. Perform adrenalectomy during the second trimester (approximately 12–24 weeks gestation).
HPIM 387 P2980
Pheochromocytomas occasionally are diagnosed in pregnancy and can be very challenging to manage. Endoscopic removal, preferably in the fourth to sixth month of gestation, is possible and can be followed by uneventful childbirth. Regular screening in families with inherited pheochromocytomas provides an opportunity to identify and remove such tumors in women of reproductive age.
94
At what level Hounsfield Units (HU) of Unenhanced CT is the presence of pheochromocytoma unlikely?
a. <5 HU
b. <10 HU
c. <15 HU
d. <20 HU
B. <10 HU
HPIM 387 P2977
Diagnostic Imaging A variety of methods have been used to localize pheochromocytomas and paragangliomas. CT and MRI are similar in sensitivity
and should be performed with contrast. T2-weighted MRI with gadolinium contrast is optimal for detecting pheochromocytomas and is somewhat better than CT for imaging extra-adrenal pheochromocytomas and paragangliomas. About 5% of adrenal incidentalomas, which usually are detected by CT or MRI, prove to be pheochromocytomas upon endocrinologic evaluation, but the presence of pheochromocytomas is unlikely if unenhanced CT reveals an attenuation of < 10 HU.
95
Which of the following patients is NOT a candidate for screening for mineralocorticoid excess?
a. A 45-year-old man with BP 165/100 mmHg on amlodipine, losartan, and hydrochlorothiazide, serum potassium 3.0 mmol/L.
b. A 39-year-old woman with BP 120/80 mmHg, serum potassium 3.4 mmol/L, and an incidentally discovered 2.5 cm left adrenal mass on CT.
c. A 32-year-old man with BP 150/90 mmHg on losartan and hydrochlorothiazide, serum potassium 4.0 mmol/L, and no adrenal mass. His father had a stroke at 38 years old.
d. A 50-year-old woman with BP 170/105 mmHg on amlodipine, metoprolol, losartan, and spironolactone, serum potassium 4.1 mmol/L, no adrenal mass on CT.
B – This patient has an incidentaloma, but has no hypertension, so she is not a candidate for screening for mineralocorticoid excess.
Choice A presents with severe hypertension and hypokalemia.
Choice C presents with hypertension and family history of early-onset cerebrovascular disease.
Choice D presents with drug-resistant hypertension.
96
Which of the following patients meets the criteria for metabolic syndrome according to the harmonizing definition?
a. Eisen, 55-year-old Japanese man: waist circumference 83 cm, triglycerides 160 mg/dL, BP 128/80 mmHg, fasting glucose 95 mg/dL.
b. Frieren, 49-year-old South Asian woman: waist circumference 82 cm, HDL 55 mg/dL, BP 135/88 mmHg, fasting glucose 99 mg/dL.
c. Himmel, 60-year-old Europid man: waist circumference 96 cm, triglycerides 170 mg/dL, HDL 38 mg/dL, fasting glucose 102 mg/dL.
d. Flamme, 52-year-old Chinese woman: waist circumference 78 cm, triglycerides 160 mg/dL, HDL 48 mg/dL, fasting glucose 90 mg/dL.
C. Himmel, 60-year-old Europid man: waist circumference 96 cm, triglycerides 170 mg/dL, HDL 38 mg/dL, fasting glucose 102 mg/dL.
97
Which of the following medications for dyslipidemia may limit the progression of diabetic retinopathy?
a. Statins
b. Niacin
c. Fibrates
d. PCSK9 Inhibitors
C. Fibrates
Once advanced retinopathy is present, improved glycemic control imparts less benefit, although adequate ophthalmologic care can prevent most
blindness. Lowering elevated levels of triglycerides with fenofibrate may reduce the progression of retinopathv.
98
In a patient with plasma glucose concentration< 55 mg/dL, which of the following diagnostic findings is consistent with endogenous hyperinsulinism?
a. Plasma insulin concentration >15 pmol/L
b. Plasma C peptide concentration of > 0.6 ng/mL
c. Plasma proinsulin concentration > 4.0 pmol/L
d. Plasma B hydroxybutyrate of < 3.0 mmol/L
B. Plasma C peptide concentration of > 0.6 ng/mL
HPIM Chapter 406 P 3133
Critical diagnostic findings are a plasma insulin concentration ≥3 4U/mL (≥18 pmol/L), a plasma C-peptide concentration ≥0.6 ng/mL (<0.2 nmol/L), and a plasma proinsulin concentration ≥5.0 pmol/L when the plasma glucose concentration is <55 mg/dL (<3.0 mmol/L) with symptoms of hypoglycemia. A low plasma ß-hydroxybutyrate concentration (≤2.7 mmol/L) and an increment in plasma glucose level of >25 mg/d (>1.4 mmol/L) after IV administration of glucagon (1.0 mg) indicate increased insulin (or IGF) actions.
99
Which of the following patients with asymptomatic primary hyperparathyroidism is the best candidate for surgical management?
a. A 67-year-old woman with serum calcium 8.5mg/dL, creatinine clearance 80 mL/min, no nephrolithiasis, and T-score –1.8 at the femoral neck.
b. A 46-year-old man with serum calcium 10mg/dL, creatinine clearance 67 mL/min, normal kidney ultrasound
c. A 58-year-old woman with serum calcium 9.0 mg/dL, creatinine clearance 70 mL/min, T-score –2.0 at the lumbar spine, and no kidney stones.
d. A 49-year-old man with serum calcium 11.9 mg/dL, creatinine clearance 58 mL/min, T-score –2.7 at the hip, and nephrolithiasis on CT.
D. A 49-year-old man with hypercalcemia, renal impairment, osteoporosis, and nephrolithiasis.
Rationale:
Choice D meets all 4 criteria (age <50, Ca >1 mg/dL above normal, renal impairment, osteoporosis/nephrolithiasis) → strongest surgical candidate.t
100
Monitoring of creatinine in patients with asymptomatic primary hyperparathyroidism should be done _________
a. Annually
b. Every 1-3 years
c. Twice a year
d. Every quarter
A. Annually
101
Which of the following patients qualifies for bone mineral density (BMD) testing?
a. A 62-year-old postmenopausal woman with no additional risk factors.
b. A 55-year-old man with no fracture history or risk factors.
c. A 72-year-old man with no history of fractures or risk factors.
d. A 48-year-old woman with rheumatoid arthritis taking 4 mg prednisone daily for 4 months.
C. A 72-year-old man with no history of fractures or risk factors.
* Women ≥65 or men ≥70 → BMD testing regardless of risk factors (C qualifies).
* Younger postmenopausal women or men 50–69 need clinical risk factors (A and B do not qualify without risk factors).
* Glucocorticoid therapy → must be >5 mg prednisone daily for >3 months (D is below threshold at 4 mg).
102
All of the following bisphosphonates are approved for the treatment of osteoporosis in men EXCEPT
a. Alendronate
b. Risedronate
c. Ibandronate
d. Zoledronic acid
C. Ibandronate
HPIM Chapter 411 page 3205 Bisphosphonates have become the mainstay of osteoporosis treatment, in part related to cost as they become generic. Alendronate, risedronate, ibandronate, and zoledronic acid are approved for the prevention and treatment of postmenopausal osteoporosis. Alendronate, risedronate, and zoledronic acid are also approved for the treatment of steroid-induced osteoporosis, and risedronate and zoledronic acid are approved for prevention of steroid-induced osteoporosis. Alendronate, risedronate, and zoledronic acid are also approved for treatment of osteoporosis in men.
103
A 21 year-old male came with a 2-year history or gradually enlarging neck mass. Biopsy revealed poorly differentiated carcinoma. Patient is up and about > 50% of waking hours. He is restricted in physically strenuous activity, yet able to carry out light housework and office work. What is the Eastern Cooperative Oncology Group (ECOG) Performance Scale grade of this patient?
a. ECOG 0
b. ECOG 1
c. ECOG 2
d. ECOG 3
B. Since patient is still able to do light work, this is considered ECOG 1.
104
Which of the following patients should undergo lung cancer screening?
a. 50 year-old male 30 pack-year active smoker with 2-month history of chronic cough and progressive exertional dyspnea, left shoulder pain, bimanual edema, clubbing, and facial plethora
b. 54 year-old female 10 pack-year former smoker (who stopped 20 years ago) coming for annual physical check-up
c. 60 year-old male 5 pack-year former smoker (who stopped 10 years ago) coming for annual physical check-up
d. 82 year-old female former 20 pack-year smoker (who stopped 15 years ago) coming for annual physical check-up
C. Choice A is wrong because low dose CT scan in his case would no longer constitute screening, but workup / diagnosis. Choice B is wrong, because patient is still not yet within the appropriate age for screening (55-80 years old for USPSTF or 55-74 years old for ACS), and patient stopped more than 15 years ago already. Choice D is wrong because patient is beyond the appropriate age, and clinical benefit may be uncertain.
105
Which of the following etiologies of thyrotoxicosis is classified under secondary hyperthyroidism?
A. Thyrotoxicosis factitia
B. Radiation-induced thyroiditis
C. Struma ovarii
D. Chorionic gonadotropin-secreting tumor
D.
106
Which of the following findings is consistent with primary adrenal insufficiency?
A . History of head trauma
B, Low-normal ACTH, Normal Renin, Normal Aldosterone
C . High ACTH, High Renin, Low Aldosterone
D. History of glucocorticoid use
C. High ACTH, high renin, low aldosterone
B is secondary
PSBIM 2026 👯♀️
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