High-Yield Systems Q&A

Endocrine
1- A 42-year-old woman with a history of pernicious anemia comes to the physician
complaining of increased anxiety, heart palpitations, heat intolerance, unexplained
weight loss, and multiple daily bowel movements. She has not had a period in 4
months. On physical examination, the patient is found to have a goiter, a thyroid
bruit, and mild exophthalamos. Laboratory studies show elevated triiodothyronine
and free thyroxine levels, and undetectable thyroid-stimulating hormone. Which of
the following is the most likely etiology of this patient's disease?
a. Autoimmune stimulation of thyroid stimulating hormone
b. Idiopathic replacement of thyroid tissue with fibrous tissue
c. Thyroid adenoma
d. Thyroid hormone-producing ovarian teratoma
e. Viral infection leading to destruction of thyroid tissue
2- A 5-year-old girl is brought to the pediatrician by her mother because she has noted
a single soft, nontender mass underneath her daughter's tongue. The physician
reassures the mother that it is a common congenital ectopic anomaly that doesn't
affect the function of the mass or the hormone it secrets. Hypersecretion of of this
hormone can cause which of the following conditions?
a. Amenorrhea
b. Cold intolerance
c. Constipation
d. Hyperlipidemia
e. Weight gain
3- A 34-year-old man with moderately severe ulcerative colitis has been taking oral
prednisone for 4 months. Which of the following symptoms is the most likely
adverse effect of this drug?
a. Diabetes insipidus
b. Diabetes mellitus
c. Hyperpigmentation of the skin
d. Hypotension
e. Muscle hypertrophy
f. Sodium wasting
4- A 45-year-old man with type 2 diabetes mellitus undergoes a neurologic
examination. The patient is unable to sense the vibration produced by the tuning
fork placed on his big toe. Which of the following receptors most likely affected in
this patient?
a. Krause end bulbs
b. Meissner's corpuscle
c. Merkel nerve endings
d. Pacinian corpuscle
e. Ruffini corpuscle
5- A 53-year-old woman with newly diagnosed type 2 diabetes presents to the
emergency department complaining of vomiting, severe headache, dizziness, blurry
vision, and difficulty breathing. She says that she had been at a cocktail party when
the symptoms began. Her skin is notably flushed on physical examination. Which of
the following medications is responsible for this reaction?
a. Acarbose
b. Glipizide
c. Glyburide
d. Metformin
e. Tolbutamide
f. Troglitazone
6- A 25-year-old man comes to the emergency department after experiencing tremors.
He appears visibly anxious and relates a recent history of sweats, nausea, vomiting
and lightheadedness. Laboratory studies show a blood glucose level of 50 mg/dL. An
abdominal CT scan shows a 1.5-cm mass in the head of the pancreas. Surgical
resection of this mass will necessitate ligation of branches from which of the
following vascular structures?
a. The gastroduodenal and inferior mesenteric arteries
b. The gastroduodenal and superior mesenteric arteries
c. The left gastric and inferior mesenteric arteries
d. The left gastric and superior mesenteric arteries
e. The proper hepatic and inferior mesenteric arteries
f. The proper hepatic and superior mesenteric arteries
7- A 36-year-old woman presents to the physician with amenorrhea. She reports an
increase in show sizes over the past year, increased sweating, and increased fatigue.
Physical examination shows a blood pressure of 150/90 mm Hg and coarse facial
features with mild macroglossia. Which of the following is most appropriate for this
patient?
a. Finasteride
b. Leuprolide
c. Octreotide
d. Recombinant growth hormone
e. Somatrem
8- A 23-year-old man comes to the physician because of intermittent severe
headaches, anxiety, heart palpitations. While he has no significant medical history,
his uncle had similar symptoms. When probed for a deeper family history, he says
that his mother and two cousins have had their thyroids removed. Which of the
following conditions most likely accounts for the clinical scenario?
a. Acromegaly
b. ACTH-secreting pituitary adenoma
c. Hyperparathyroidism
d. Nonfunctioning pituitary adenoma
e. Pheochromocytoma
9- Growth hormone is essential to normal human growth and development, and its
secretion is tightly regulated via feedback control system involving the
hypothalamus, the pituitary gland, and the peripheral tissues. Which of the following
is a stimulus for the secretion of growth hormone?
a. Hypoglycemia
b. Obesity
c. Pregnancy
d. Somatomedin excess
e. Somatostatin therapy
10- A 66-year-old man with chronic cough, dyspnea, and a 50-pack-year history of
cigarette smoking comes to the clinic after noticing blood in his sputum . He says he
feels lethargic and has lost 18 kg (40 lb) over the past 3 months with no changes in
diet or exercise. Laboratory studies show a serum sodium level of 120 mEq/L. While
awaiting CT, the patient suffers a seizure and is rushed to the emergency
department. Which of the following is most likely to be elevated in this patient?
a. ACTH
b. ADH
c. Parathyroid hormone
d. Renin
e. Tumor necrosis factor-α
11- A 43-year-old woman presents with fatigue, a 4.5-kg (9.9-lb) weight gain over the
past 3 months, cold intolerance, hair loss, and concentration problems. Physical
examination is significant for dry, coarse skin and bradycardia. She states that she
had some slight swelling of her lower neck several months ago, which resolved
without treatment. Results of antithyroglobulin antibody tests are negative, but a
thyroid peroxidase antibody test is positive. What other autoimmune diseases will
this patient most likely have?
a. Grave's disease and pernicious anemia
b. Osteoarthritis and Addison's disease
c. Rheumatoid arthritis and vitiligo
d. Type 1 diabetes mellitus and celiac disease
e. Whipple's disease and type 1 diabetes mellitus
12- A 60-year-old woman with a history of type 2 diabetes mellitus comes to the clinic
for a follow-up examination after being placed on a new agent to help her achieve
tighter glycemic control. She complains that she has suffered occasional abdominal
cramps and diarrhea, adding that she has recently been experiencing increase
flatulence, which has become an embarrassing nuisance. Which of the following
agents best accounts for this patient's complaints?
a. Acarbose
b. Chlorpropamide
c. Glipizide
d. Metformin
e. Orlistat
f. Troglitazone
13- A 39-year-old woman is seen by a physician because of a lump in the front of her
neck. Physical examination reveals a swollen thyroid gland. A biopsy of the enlarged
but painless thyroid gland is found to contain psammoma bodies and thin
projections of epithelium surrounding a fibrovascular core. The nuclei of many cells
are optically clear. Which of the following risk factors is most commonly associated
with her diagnosis?
a. Chronic cigarette smoking
b. Preexisting Grave's disease
c. Presence of HLA-DR5 receptors
d. Prior radiotherapy to the head or neck
e. Recent pregnancy
14- A 54-year-old man with a history of smoking and lung cancer develops
hypercalcemia. He is enrolled in a research study to assess the efficacy of a new
synthetic agent to treat this condition. After several days of treatment, he reports
persistent numbness and tingling around his mouth. Physical examination is
significant for facial spasm when the jaw is tapped and carpal spasm when the blood
pressure cuff is inflated. Which of the following was most likely used to treat his
hypercalcemia?
a. Calcitonin
b. Parathyroid hormone
c. Parathyroid hormone related-peptide
d. Thyroxine
e. Vitamin D
15- A 34-year-old woman goes to her primary care physician complaining of a recent
feeling that "her heart was racing" and visual changes. During the interview, the
physician notices that the patient is clearly anxious. During the review of systems,
the patient reveals a recent unintentional 4-kg (8.8-lb) weight loss. On physical
examination, the physician notes that the patient is tachycardiac and has 2+
nonpitting edema in her lower extremities. Which of the following is the most likely
etiology of this disease.
a. Autoantibodies to the thyroid-stimulating hormone receptor
b. Circulating antibodies to thyroid peroxidase and thyroglobulin
c. Hyperfunctioning thyroid nodule
d. Iodine deficiency
e. Reaction to radiation
16- A researcher investigating the action of thyroid hormones wants to develop an assay
to analyze the activity of this hormone in various tissues. Which of the following
strategies would be most effective in determining the level of activity of these
hormones in a tissue sample?
a. Assessing cAMP levels
b. Assessing intracellular calcium levels
c. Assessing Na⁺/K⁺-ATPase mRNA levels
d. Assessing phospholipase C activity
e. Assessing phosphorylation of insulin receptor substrate 1
17- A 25-year-old woman presents to a primary care clinic complaining of galactorrhea,
loss of libido, and vision changes. Further work-up reveals a mass in the sella turcica.
Which of the following functions will most likely be preserved with normal
functioning in this individual?
a. Free water resorption
b. Menstruation
c. Ovulation
d. Salt retention
e. Thyroid hormone production
18- A 24-year-old woman who has never been pregnant presents to her physician with
galactorrhea. Her past medical history is significant for hypercalcemia and recurrent
duodenal ulcers. Maternal family members have been diagnosed with a variety of
tumors. Which of the following is the genetic inheritance pattern of this patient's
disorder?
a. Autosomal dominant
b. Autosomal recessive
c. Mitochondrial
d. X-linked dominant
e. X-linked recessive
19- A 28-year-old man with a history of hypothyroidism comes to the physician because
of a 3-day history of abdominal pain, diarrhea, palpitations, and fatigue. Physical
examination is remarkable only for tachycardia. Which of the following medications
most likely accounts for the patient's presentation?
a. Dobutamine
b. Iodide
c. Leuprolide
d. Levothyroxine
e. Propylthiouracil
20- A 33-year-old woman with diabetes mellitus presents to the physician with loss of
vision in both eyes. On physical examination, she is noted to be of tall stature with a
lantern jaw, a prominent nose, and supraorbital ridges. She reports excessive
sweating and progressive increase in her ring size. An MRI shows a mass at the base
of the patient's brain; a biopsy is performed. Which of the following describes how
this biopsied mass would most likely appear on staining?
a. Acidophilic
b. Basophilic
c. Chromophobic
d. Mixed acidophilic and basophilic
e. Mixed basophilic and chromophobic
Answers:
1- The correct answer is A. The patient presents as a classical case of Grave's
disease. In Graves' disease, the thyroid-stimulating IgG antibodies bind to TSH
receptors and lead to thyroid hormone production. This causes glandular
hyperplasia associated with Graves' disease. Graves' disease is the most
common cause of thyrortoxycosis. Patients with this condition may have other
autoimmune diseases, such as pernicious anemia or type 1 diabetes mellitus,
and frequently present with anxiety, irritability, tremor, heat intolerance with
sweaty skin, tachycardia and cardiac palpitations, weight loss, increased
appetite, fine hair, diarrhea, and amenorrhea oligomenorrhea. Signs include
diffuse goiter, proptosis, periorbital edema, and thickened skin on the lower
extremities. Laboratory values reveal increased thyroid hormone levels and
decreased TSH levels.
2- The correct answer is A. Usually the thyroid gland develops beneath the tongue,
descends along the thyroglossal duct, and eventually resides anterior to the
trachea in the neck. Ectopic thyroid tissue may be found anywhere along the
course of the duct, including its place of origin: beneath the tongue. This is a
common congenital anomaly that doesn’t affect thyroid function, and it should
not be removed. Hypersecretion of thyroxin (T₄) from the ectopic gland can
result in menstrual abnormalities, including amenorrhea and oligomenorrhea.
3- The correct answer is B. This patient is at risk for prednisone-induced Cushing's
syndrome. Cushing's is associated with diabetes mellitus which can be an
adverse effect of chronic corticosteroid use owing to decreased glucose
tolerance and the counterregulatory action of the hormone. Glucocorticoids
increase the glucose production by the liver in part by stimulating
gluconeogenesis, and also by stimulating proteolysis in the skeletal muscle and
releasing glucogenic amino acids into the vasculature.
4- The correct answer is D. The sensory receptors responsible for transducing the
sensation of vibration, pressure, and tension are the large encapsulated pacinian
corpuscle, which are located in the deeper layer of the skin, ligaments, and joint
capsules. They can be distinguished histologically by their onion-like appearance
on the cross section. This patient is presenting with one of the complications of
diabetes, neuropathy and since pacinian corpuscles are responsible for
transducing vibratory stimuli, it is these receptors that are involved in this
patient's presentation.
5- The correct answer is E. This patient had a disulfiramlike reaction after drinking
alcohol at a cocktail party. Of the diabetes medications listed, only tolbutamide
is associated with causing a disulfiramlike reaction after alcohol consumption.
Tolbutamide is a sulfonylurea antidiabetic agent. Sulfonylureas lower blood
glucose in patients with type 2 diabetes by directly stimulating the release of
insulin from the pancreas. They do this by binding to the sulfonylurea receptor
on the β islet cell, leading to the inhibition of potassium ion efflux, cell
depolarization, subsequent opening of voltage-gated calcium channels, and
calcium influx which triggers the release of preformed insulin. Other drugs
 known to cause a disulfiramlike reaction include metronidazole, quinacrine,
griseofulvin, and chloramphenicol, as well as some cephalosporins including
cefamandole and cefoperazone.
6- The correct answer is B. The head of the pancreas and duodenum share a dual
blood supply from the gastroduodenal artery, a branch of the celiac trunk. This
artery supplies the anterior and posterior superior pancreaticoduodenal arteries
as well as the superior mesenteric artery, which supplies the anterior and
posterior inferior pancreaticoduodenal arteries. Therefore, to resect any portion
of the duodenum or the head of the pancreas, branches from both
gastroduodenal and superior mesenteric arteries must be ligated.
7- The correct answer is C. This patient presents with acromegaly, the clinical
syndrome that is a result of excessive growth hormone (GH) secretion in adults
(after closure of the physes). Octreotide is a somatostatin analog that acts at the
anterior pituitary to suppress GH secretion, and is used in the treatment of
acromegaly. Surgical and radiotherapeutic approaches are also an option,
depending on the etiology. Somatostatin is normally secreted by the
hypothalamus to help regulate basal GH secretion.
8- The correct answer is E. The headache, anxiety, and palpitations suggest an
excess of catecholamines stimulating the sympathetic nervous system. A
pheochromocytoma may be suspected, and since there appears to be a familial
involvement, the related multiple endocrine neoplasia (MEN) syndromes should
also be considered. MEN type II (used to be called type 2a) consists of medullary
thyroid carcinoma (MTC), pheochromocytoma, and tumors of the parathyroid.
MEN type III (used to be type 2b) usually includes MTC, pheochromocytoma,
and neuromas instead of parathyroid tumors. It is therefore likely that this
patient's relatives had their thyroids removed due to MTC. One could further
differentiate the two types by looking for neuromas on the lips, tongue, or
eyelids or in the gastrointestinal tract causing constipation/diarrhea, or for
hyperparathyroidism manifesting in bradycardia, hypotonia, fatigue and bone
pain.
9- The correct answer is A. In addition to being necessary to normal human growth
and development, GH is critical in the stress response to starvation. GH is
released in response to hypoglycemia and acts directly to decrease glucose
uptake by cells and increase lipolysis, resulting in an increase in blood sugar
levels.
10- The correct answer is B. The vignette is most consistent with a syndrome of
inappropriate secretion of ADH due to a lung neoplasm. ADH is secreted by the
posterior pituitary and stimulates the expression of aquaporins in the renal
collecting ducts, resulting in transport of water into the renal medulla from the
ductal lumen and hence water retention in the kidneys. When levels of this
hormone are inappropriately elevated, excessive water retention results in
hyponatremia, which can lead to seizures. ADH can be produced ectopically in
the setting of malignancy, classically by small cell lung cancer.
11- The correct answer is D. This patient has Hashimoto's thyroditis, an
autoimmune disorder in which patients have antibodies attacking thyroglobulin,
 thyroid peroxidase, or another part of the thyroid gland or thyroid hormone
synthesis pathway. Patients with Hashimoto's thyroiditis have a 20 times greater
prevalence of celiac disease and type 1 diabetes mellitus than the general
population.
12- The correct answer is A. Acarbose is an α-glucosidase inhibitor that decreases
the hydrolysis and absorption of disaccharides and polysaccharides at the
intestinal brush border, thereby reducing postprandialhyperglycemia. This drug
can be used as monotherapy or in combination with oral hypolglycemic
medications in the management of type 2 diabetes mellitus. Acarbose
commonly causes gastrointestinal adverse effects that include abdominal
cramps, diarrhea, and flatulence.
13- The correct answer is D. Papillary thyroid carcinoma is the most common type
of thyroid cancer. It is always distinguished by its finger-like projections of
epithelium surrounding a central fibrovascular core, calcified spheres
(psammoma bodies), optically clear "Orphan Annie" nuclei, and molding of the
nuclei. Patients often have a prior history of radiation to the head or neck.
Papillary thyroid carcinoma carries a better prognosis than the other forms of
thyroid cancer.
14- The correct answer is A. This vignette describes a patient with classic symptoms
and signs of hypocalcemia, including Chvostek's sign (facial spasm) and
Trousseau's sign (carpal spasm). All of these findings can be attributed to the
physiological effects of calcitonin. Calcitonin is normally secreted in response to
elevated serum calcium and causes decreased bone resorption of calcium,
resulting in lower calcium levels.
15- The correct answer is A. This patient has Graves' disease, an autoimmune
disorder resulting from IgG-type autoantibodies to the thyroid-stimulating
hormone receptor. The three classic findings associated with Graves' disease are
hyperthyroidism, ophthalmopathy, and dermopathy/pretibial myxedema.
16- The correct answer is C. Thyroid hormones act via a nuclear hormone receptor.
On binding with its ligand, the receptor translocates from the cytoplasm to the
cell nucleus, and the ligand-receptor complex acts as a transcription factor. This
results in gene transcription and new protein synthesis. This answer is the only
one that involves assessment of gene transcription, and thus represents the only
selection that refers to the nuclear hormone receptor mechanism. Furthermore,
an important function of thyroid hormones is increasing basal metabolic rate,
which is mediated by increasing Na⁺/K⁺-ATPase expression and activity. Other
hormones that act through nuclear steroid hormone receptors include cortisol,
aldosterone, vitamin D, testosterone, estrogen, and progesterone.
17- The correct answer is D. Pituitary adenomas can lead to hypersecretion of
hormones as demonstrated by this woman's galactorrhea suggesting high levels
of prolactin. Due to their mass effect, an adenoma can also lead to deficiencies
in other pituitary hormones and changes in vision. The key to answering this
question is to realize which of the processes listed is not changed by a deficiency
on a pituitary hormone. Salt retention is a primary action of aldosterone, which
acts at the renal distal tubules to increase sodium and chloride reabsorption as
 well an increase potassium secretion. Aldosterone is produced in a multistep
pathway from cholesterol , along with cortisol and the androgens, in response to
ACTH stimulation. ACTH is secreted by the anterior pituitary and would likely be
deficient due to impingement of an adenoma on this gland. However, ACTH
deficiency does not cause salt wasting, volume contraction, and hyperkalemia
because it does not result in clinically important deficiency of aldosterone.
18- The correct answer is A. The patient has tumors involving the "3 P's" of MEN
type I. also known as Werner's syndrome. Her galactorrhea is likely due to
Prolactin-secreting Pituitary tumor, and her hypercalcemia is likely due to a
Parathyroid adenoma. Her recurrent duodenal ulcers are manifestations of a
gastrin-secreting tumor frequently located in the Pancreas, as seen in Zollinger-
Ellison syndrome, the genetic inheritance of MEN I is autosomal dominant, as
one would expect if multiple maternal family members are also affected by this
disorder.
19- The correct answer is D. This patient presents with thyrotoxicosis, which can
result due to excess endogenous of exogenous thyroid hormone. Levothyroxine
is a synthetic form of thyroxine that is used in treatment of hypothyroidism.
Excessively high serum levels of levothyroxine result in symptoms of
thyrotoxicosis, including those described in the vignette as well as heat
intolerance, unexplained weight loss, agitation, and confusion.
20- The correct answer is A. The patient is showing signs and symptoms of
acromegaly. On further testing, the bilateral vision loss is likely to be bitemporal
hemianopsia from the GH-secreting adenoma compressing the optic chiasm.
GH-secreting tumors cause gigantism if the epiphyses have not closed, as in
children, and cause acromegaly in adults. Other characteristics of acromegaly
include coarse features such as enlarged jaw, face, hands, and feet.
Osteoporosis, hyperglycemia, and hypertension may also be associated with
excess GH secretion. This second most common pituitary tumor is composed of
acidophilic-staining cells.

Resource: First Aid Q & A for the USMLE Step 1, 2nd Edition