Endocrinology Practice Questions

Q: Which of the following most strongly suggests the diagnosis of primary hyper-parathyroidism ?

Serum calcium above 11 mg/dL. ***Serum calcium above 11 mg/dL*** - **Hypercalcemia** is the hallmark of primary hyperparathyroidism, as excessive parathyroid hormone (PTH) leads to increased calcium reabsorption from bones and kidneys [1, 3]. - A serum calcium level significantly above the normal range (typically 8.5-10.2 mg/dL) strongly suggests a parathyroid-related issue; specifically, levels exceeding 11.4 mg/dL (2.85 mmol/L) often warrant surgical consideration [1]. *Serum acid phosphatase above 120 IU/L* - **Elevated acid phosphatase** is more commonly associated with conditions like **prostatic carcinoma** with bone metastases or certain hematologic malignancies. - It is not a primary diagnostic marker for hyperparathyroidism. *Urinary calcium below 100 mg/day* - **Low urinary calcium** (hypocalciuria) is characteristic of **familial hypocalciuric hypercalcemia (FHH)**, a genetic condition that can mimic primary hyperparathyroidism [1]. - In primary hyperparathyroidism, **urinary calcium excretion is typically normal or high** due to the PTH-mediated increase in filtered calcium load. *Serum alkaline phosphatase above 120 IU/L* - **Elevated alkaline phosphatase** can indicate increased **bone turnover**, which can be seen in severe, prolonged primary hyperparathyroidism as an indicator of bone resorption [1, 2]. - However, it is a non-specific marker and can also be elevated in various liver diseases or other bone disorders; it is not as specific as hypercalcemia for diagnosing primary hyperparathyroidism [2].

Q: Serum calcitonin may be elevated in

medullary carcinoma of thyroid. ***medullary carcinoma of thyroid*** - **Medullary thyroid carcinoma (MTC)** originates from the **parafollicular C cells** of the thyroid gland, which physiologically produce and secrete **calcitonin**. - Therefore, MTC is a classic cause of significantly elevated serum **calcitonin** levels, used both as a diagnostic marker and for monitoring disease recurrence. *choriocarcinoma of ovary* - **Choriocarcinoma** is a germ cell tumor that typically produces **human chorionic gonadotropin (hCG)**, not calcitonin [3]. - Ovarian choriocarcinoma is a rare and highly aggressive tumor, and its primary tumor marker is **hCG** [3]. *islet cell tumour of pancreas* - **Islet cell tumors** of the pancreas (neuroendocrine tumors) typically produce hormones like **insulin, glucagon, somatostatin, or gastrin**, depending on their subtype [1], [2]. - While they are endocrine tumors, they do not originate from calcitonin-producing cells and thus generally do not elevate **calcitonin**. *carcinoid tumour of appendix* - **Carcinoid tumors**, especially those of the appendix, are **neuroendocrine tumors** that typically secrete **serotonin** and other vasoactive substances [1]. - These tumors are associated with **carcinoid syndrome** (flushing, diarrhea, bronchospasm) but do not produce **calcitonin** [1].

Q: Insulin Resistance Syndrome (Syndrome X) is associated with which of the following? 1. Type 2 Diabetes Mellitus 2. Hyperinsulinaemia 3. Dyslipidaemia 4. Hypercalcaemia

1, 2 and 3. ***1, 2 and 3*** - **Insulin Resistance Syndrome** (metabolic syndrome) is characterized by a cluster of conditions including **insulin resistance**, **type 2 diabetes mellitus**, **hyperinsulinemia**, and **dyslipidemia** [1], [2]. - **Hyperinsulinemia** results from the pancreas overproducing insulin to compensate for tissue insensitivity, and **dyslipidemia** (abnormal lipid levels) is a common component [1]. *1, 3 and 4* - This option correctly identifies **type 2 diabetes mellitus** and **dyslipidemia** as components of insulin resistance syndrome but incorrectly includes **hypercalcemia**. - **Hypercalcemia** (high calcium levels) is not a defining feature or direct consequence of insulin resistance syndrome. *2, 3 and 4* - This option includes **hyperinsulinemia** and **dyslipidemia**, which are core features, but incorrectly includes **hypercalcemia**. - It also omits **type 2 diabetes mellitus**, which is a significant clinical manifestation of prolonged insulin resistance [1]. *1, 2 and 4* - This option correctly identifies **type 2 diabetes mellitus** and **hyperinsulinemia** as associated conditions but incorrectly includes **hypercalcemia**. - This option omits **dyslipidemia**, which is a very common and important component of the metabolic syndrome, contributing to cardiovascular risk.

Q: A few days following viral fever, a 50 year old female presented with pain in neck, fever, malaise and firm enlargement of both the lobes of thyroid. On investigation thyroid antibodies were normal & serum T4 was high normal. Probable diagnosis is:

Granulomatous thyroiditis. ***Granulomatous thyroiditis*** - The presentation of **neck pain**, **fever**, **malaise**, and **firm, enlarged thyroid lobes** following a viral fever, along with normal thyroid antibodies and high-normal T4, is highly characteristic of **subacute granulomatous thyroiditis (de Quervain's thyroiditis)** [1]. - This condition is typically **post-viral**, causes inflammation leading to temporary hyperthyroidism due to hormone release, and is often painful [1]. *Lymphoma of thyroid* - Thyroid lymphoma usually presents as a **rapidly growing neck mass** in older individuals and is not typically preceded by a viral illness. - It is less commonly associated with pain and fever in this manner, and thyroid function can be variable. *Riedel's thyroiditis* - **Riedel's thyroiditis** is a rare, invasive fibrosis of the thyroid and surrounding structures, leading to a **rock-hard, painless goiter**. - It does not typically follow a viral infection with acute pain and fever or present with high-normal T4. *Autoimmune thyroiditis* - **Autoimmune thyroiditis (Hashimoto's thyroiditis)** is characterized by elevated thyroid antibodies and typically presents with **hypothyroidism**, often with a **painless goiter**. - It does not usually follow a viral illness with acute pain and fever or cause temporary thyrotoxicosis with normal antibodies [1].

Q: Which one of the following is NOT correct regarding MEN-1 syndrome?

It involves pineal gland. ***It involves pineal gland*** - MEN-1 syndrome, also known as Wermer's syndrome, is characterized by tumors of the **parathyroid glands**, **pituitary gland**, and **pancreatic islet cells** [1]. - The **pineal gland** is not typically associated with MEN-1 syndrome. *It involves pancreas* - **Pancreatic islet cell tumors** are a hallmark of MEN-1, often leading to diseases like **Zollinger-Ellison syndrome** (gastrinomas) or insulinomas [1]. - These tumors can cause significant endocrine dysfunction due to excessive hormone production [1]. *It involves pituitary gland* - **Pituitary adenomas**, particularly prolactinomas, are a common manifestation of MEN-1 syndrome [1]. - They can cause symptoms related to hormone excess (e.g., galactorrhea) or mass effects (e.g., visual disturbances) [1]. *It involves parathyroid glands* - **Hyperparathyroidism** due to parathyroid adenomas or hyperplasia is the most common manifestation of MEN-1 syndrome, affecting nearly all patients [2]. - This leads to elevated **calcium levels** and can cause symptoms like kidney stones, bone pain, and fatigue.

Q: Medical management of thyrotoxic crisis includes all of the following EXCEPT:

IV antibiotics. ***IV antibiotics*** - **Antibiotics** are not a primary treatment for **thyrotoxic crisis** itself unless there's an underlying infection triggering the crisis, which is not indicated as a universal management step [1]. - The crisis is caused by an acute exacerbation of **hyperthyroidism**, not bacterial infection, so antibiotics would not address the core pathophysiology. *IV propanolol* - **Propranolol** (or other beta-blockers) helps control the adrenergic symptoms of thyrotoxic crisis, such as **tachycardia**, **tremors**, and **anxiety** [1]. - It also inhibits the peripheral conversion of **T4 to T3**, providing an additional therapeutic effect. *IV hydrocortisone* - **Glucocorticoids** like **hydrocortisone** are crucial in thyrotoxic crisis to inhibit the peripheral conversion of **T4 to T3**, stabilize cell membranes, and provide adrenal support. - They also help manage potential adrenal insufficiency, which can be an exacerbating factor or complication. *IV fluids* - **Intravenous fluids** are essential for correcting **dehydration**, which is often present due to increased metabolic rate, fever, sweating, and vomiting in patients with thyrotoxic crisis [1]. - They also help address **electrolyte imbalances** and support cardiovascular stability.

Q: A woman presents with altered sensorium, breathlessness, hypotension and bradycardia. Examination revealed non-pitting edema of the extremities. She has a long -standing history of weight gain, constipation, cold intolerance, and menorrhagia. What is the most likely diagnosis?

Myxedema coma. ***Myxedema coma*** - The constellation of **altered sensorium**, **hypotension**, **bradycardia**, and **non-pitting edema** in a patient with a history of **weight gain**, **constipation**, **cold intolerance**, and **menorrhagia** (symptoms of hypothyroidism) is highly suggestive of myxedema coma [2]. - This is an **extreme manifestation of severe, untreated hypothyroidism**, characterized by decompensation of multiple organ systems. *Hyperthyroidism* - Hyperthyroidism usually presents with symptoms like **tachycardia**, **tremors**, **weight loss**, and **heat intolerance** [1], [3], which are contrary to the patient's presentation. - It would not explain the **bradycardia**, **non-pitting edema**, or chronic symptoms like **constipation** and **cold intolerance**. *Cardiogenic shock* - While cardiogenic shock can cause **hypotension** and **altered sensorium**, it is typically characterized by signs of **cardiac dysfunction** such as elevated JVP, crackles, and often **tachycardia** (reflexive or primary), not bradycardia [4]. - It does not account for the **long-standing hypothyroid symptoms** like weight gain, constipation, and cold intolerance. *Septic shock* - Septic shock is primarily due to a severe infection, leading to **fever** (though hypothermia can occur in severe cases), **leukocytosis**, and signs of systemic inflammatory response (SIRS), which are not mentioned. - The patient's chronic symptoms are inconsistent with an acute infectious process as the primary cause of shock.

Q: A diabetic patient's fasting blood glucose level is found to be $160 \mathrm{mg} / \mathrm{dL}$. What will you advise the patient regarding non-pharmacological management?

<30 % of the calories should come from fat. ***<30 % of the calories should come from fat*** - Reducing dietary fat intake to less than 30% of total calories is a crucial non-pharmacological strategy for diabetic patients to manage blood glucose levels and prevent cardiovascular complications [1]. - Excess dietary fat, especially saturated and trans fats, can contribute to insulin resistance and weight gain, both of which negatively impact glycemic control [1]. *At least 25-35 g of dietary fibre* - While adequate dietary fiber (typically 25-30g for adults, sometimes up to 35g for men) is beneficial for managing blood glucose, it is generally recommended as a baseline for healthy eating and not the primary or most impactful intervention to address a fasting glucose of 160 mg/dL [1]. - Fiber helps slow glucose absorption and can improve insulin sensitivity, but a specific "at least 25-35g" statement without further context on total caloric intake or other macronutrient distribution might not be the most targeted advice for this specific glucose level [1]. *Dietary cholesterol <300 mg per day* - Limiting dietary cholesterol to less than 300 mg per day is a general recommendation for cardiovascular health, which is particularly important for diabetic patients due to their increased risk of atherosclerosis [2]. - However, for directly addressing a fasting blood glucose of 160 mg/dL, focusing on overall fat intake and carbohydrate quality would have a more immediate impact on glucose control than dietary cholesterol alone. *<2.3 g sodium intake every day* - Restricting sodium intake to less than 2.3 g per day is recommended for managing hypertension and reducing cardiovascular risk, which is often comorbid with diabetes [2]. - While important for overall health in diabetic patients, this recommendation does not directly target blood glucose control and would not be the primary non-pharmacological advice for a fasting glucose of 160 mg/dL.

Q: A 66-year-old woman comes to the physician for a routine health maintenance examination. She has no history of serious medical illness and takes no medications. A screening DEXA scan shows a T-score of -1.5 at the femur. Which of the following is the strongest predisposing factor for osteopenia?

Smoking. ***Smoking*** - **Smoking** is a well-established risk factor for **osteoporosis** and **osteopenia** due to its negative effects on bone formation and density [1]. - It impairs osteoblast activity, increases osteoclast activity, and can lead to lower estrogen levels, all contributing to bone loss. *NSAID use* - **NSAIDs (nonsteroidal anti-inflammatory drugs)** are not typically associated with a risk of osteopenia or osteoporosis. - While prolonged high-dose use can have side effects, bone density reduction is not one of them. *Type 2 diabetes mellitus* - The relationship between **Type 2 diabetes mellitus** and bone health is complex; while some studies suggest an increased fracture risk, largely due to falls and poorer bone quality, it's not consistently associated with lower bone mineral density (osteopenia) itself, particularly in younger individuals, and can even be associated with higher bone density. - The primary mechanism for increased fracture risk in diabetes often relates to microvascular complications, neuropathy leading to falls, and altered bone microarchitecture rather than directly causing osteopenia. *Hypoparathyroidism* - **Hypoparathyroidism** leads to **low parathyroid hormone (PTH) levels**, which can result in increased bone mineral density rather than decreased density (osteopenia). - PTH is crucial for maintaining calcium homeostasis and bone remodeling, and its deficiency slows bone turnover, potentially making bones denser but also more brittle. *Obesity* - **Obesity** is generally considered protective against osteopenia or osteoporosis due to the increased mechanical loading on bones, which stimulates bone formation. - Adipose tissue also produces estrogen, which can help maintain bone density, particularly in postmenopausal women [2].

Question 1

Which of the following most strongly suggests the diagnosis of primary hyper-parathyroidism ?

Accepted Answer

Serum calcium above 11 mg/dL

Answer

Serum acid phosphatase above 120 IU/L

Answer

Urinary calcium below 100 mg/day

Answer

Serum alkaline phosphatase above 120 IU/L

Question 2

Serum calcitonin may be elevated in

Accepted Answer

medullary carcinoma of thyroid

Answer

choriocarcinoma of ovary

Answer

islet cell tumour of pancreas

Answer

carcinoid tumour of appendix

Question 3

Insulin Resistance Syndrome (Syndrome X) is associated with which of the following?

1. Type 2 Diabetes Mellitus
2. Hyperinsulinaemia
3. Dyslipidaemia
4. Hypercalcaemia

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 4

Question 4

A few days following viral fever, a 50 year old female presented with pain in neck, fever, malaise and firm enlargement of both the lobes of thyroid. On investigation thyroid antibodies were normal & serum T4 was high normal. Probable diagnosis is:

Accepted Answer

Granulomatous thyroiditis

Answer

Lymphoma of thyroid

Answer

Riedel's thyroiditis

Answer

Autoimmune thyroiditis

Question 5

Which one of the following is NOT correct regarding MEN-1 syndrome?

Accepted Answer

It involves pineal gland

Answer

It involves pancreas

Answer

It involves pituitary gland

Answer

It involves parathyroid glands

Question 6

Medical management of thyrotoxic crisis includes all of the following EXCEPT:

Accepted Answer

IV antibiotics

Answer

IV propanolol

Answer

IV hydrocortisone

Answer

IV fluids

Question 7

A 45-year-old man with a strong family history of multiple endocrine neoplasia type 2 (MEN2) presents for genetic counseling. He has not undergone genetic testing but has three children. His brother recently died of metastatic medullary thyroid cancer. What is the most appropriate initial approach for this patient and his family?

Accepted Answer

Genetic counseling with testing and family cascade screening

Answer

Immediate prophylactic thyroidectomy without genetic testing

Answer

Screening with calcitonin levels only

Answer

Observation with annual screening

Question 8

A woman presents with altered sensorium, breathlessness, hypotension and bradycardia.
Examination revealed non-pitting edema of the extremities. She has a long -standing history of weight gain, constipation, cold intolerance, and menorrhagia. What is the most likely diagnosis?

Accepted Answer

Myxedema coma

Answer

Hyperthyroidism

Answer

Cardiogenic shock

Answer

Septic shock

Question 9

A diabetic patient's fasting blood glucose level is found to be $160 \mathrm{mg} / \mathrm{dL}$. What will you advise the patient regarding non-pharmacological management?

Accepted Answer

<30 % of the calories should come from fat

Answer

At least 25-35 g of dietary fibre

Answer

Dietary cholesterol <300 mg per day

Answer

<2.3 g sodium intake every day

Question 10

A 66-year-old woman comes to the physician for a routine health maintenance examination. She has no history of serious medical illness and takes no medications. A screening DEXA scan shows a T-score of -1.5 at the femur. Which of the following is the strongest predisposing factor for osteopenia?

Accepted Answer

Smoking

Answer

NSAID use

Answer

Type 2 diabetes mellitus

Answer

Hypoparathyroidism

Answer

Obesity

Endocrinology — MCQs

Endocrinology — MCQs

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