Im - Endocrinology

IM - ENDOCRINOLOGY SET
1. A 30-year-old woman comes to the clinic with neck pain. Physical examination of the neck
reveals a tender thyroid gland that is diffusely enlarged. There are no thyroid nodules. The
patient is started on naproxen for the pain, and thyroid blood tests are ordered. She returns
to the clinic 2 days later for scheduled follow-up. Her thyroid pain has improved, but
now she is experiencing palpitations and fine tremor in the hands. Results from the initial
laboratory studies show a decreased serum thyroid stimulating hormone (TSH) and an
increased free thyroxine (T4). A radioactive iodine uptake scan shows decreased uptake.
a. What is the most likely diagnosis?
b. What would be the most appropriate treatment at this time?
c. What would you expect the serum TSH level to be at follow-up in 6 months?
2. For each of the following causes of Cushing syndrome, what is the most appropriate
treatment?
a.
b.
c.
d.
Exogenous glucocorticoid administration

Corticotroph pituitary adenoma
Hyperfunctioning adrenal adenoma
Ectopic ACTH production from a non-pituitary site
3. A 31-year-old woman comes to the clinic for amenorrhea for the last 6 months. She is not
pregnant and does not desire pregnancy currently. Laboratory evaluation shows a serum
prolactin level of 126 ng/mL (normal 5-20 ng/mL). An MRI of the brain shows a 3-mm
mass in the sella turcica.
a. What is the most appropriate medical management of this patient?
b. What are the indications for surgical treatment of this condition?
4. A 72-year-old man is diagnosed with type 2 diabetes. What medication is the most
appropriate first-line treatment?
[ 26 ]
a. What are the risks of giving supratherapeutic doses of levothyroxine?

b. What is the most appropriate management for this patient?
6. A 60-year-old Caucasian woman undergoes screening for osteoporosis. A dual-energy x-ray

absorptiometry (DEXA) scan shows reduced bone mineral density with a T score of -2.7. In
addition to starting treatment with a bisphosphonate, what lifestyle counseling should she
receive?
7. A 34-year-old man with a history of primary adrenal insufficiency is brought to the

emergency department because of altered mental status. His medications include his usual
doses of hydrocortisone and fludrocortisone. He is admitted to the hospital for treatment
of shock and pneumonia. Vital signs are temperature 38.6C (101.5F), heart rate 120/
min, blood pressure 80/50 mm Hg, and respirations 24/min. Laboratory studies show
hyponatremia, hyperkalemia and hypoglycemia.
a. What is the most likely cause of this patients shock?
b. What is the most appropriate management of this patient?
[ 27 ]
INTERNAL MEDICINE
5. A 53-year-old woman comes to the clinic for follow-up of chronic hypothyroidism. She is
asymptomatic on her current dose of levothyroxine, but recent laboratory studies show a
slightly suppressed thyroid stimulating hormone (TSH).
8. A 24-year-old man comes to the clinic after discovering a lump in his anterior neck while
shaving. Physical examination of the neck reveals a solitary, nontender thyroid nodule. What
is the most appropriate management for this patient?
9. A 47-year-old man comes to the emergency department with headache, diaphoresis and
tachycardia. His blood pressure is 176/99 mm Hg. He is found to have markedly elevated
levels of norepinephrine, dopamine and metanephrine in the urine. A CT scan of the
abdomen shows a 3-cm mass in the right adrenal gland.
a. What preoperative treatment is necessary in this patient?
b. What diagnoses should be considered if the CT showed bilateral adrenal masses?
c. What other disorders of the adrenal glands can cause secondary hypertension?
10. A 60-year-old man comes to the clinic with complaints of left knee pain, thigh pain and
back pain. He also mentions offhand that his favorite hat seems too tight. The physical
examination is normal. An x-ray of the knee shows a lytic lesion in the distal left femur.
Laboratory studies show normal serum calcium, phosphate, creatinine and hemoglobin. The
serum alkaline phosphatase is elevated.
a. What additional test would be most appropriate to confirm the diagnosis?
b. What is the most appropriate treatment for this condition?
[ 28 ]

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IM - ENDOCRINOLOGY SET

Exogenous glucocorticoid administration

a. What are the risks of giving supratherapeutic doses of levothyroxine?

6. A 60-year-old Caucasian woman undergoes screening for osteoporosis. A dual-energy x-ray

7. A 34-year-old man with a history of primary adrenal insufficiency is brought to the

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