Endocrinology Board Review (Block 2 of 4)

A 23-year-old Caucasian woman presents with a six-month history of progressive weight gain and amenorrhea. Her physical examination is significant for moderate hirsutism, facial plethora, and multiple violaceous striae involving the abdomen. She is noted to have significant hyperpigmentation of her palmar creases. A 1mg overnight dexamethasone suppression test was significant for a post suppression cortisol level of 3 mcg/dL. Pituitary MRI showed a 1.2 cm adenoma on the right side of the pituitary gland. Inferior petrosal sinus sampling (IPSS) confirmed the diagnosis of an ACTH-dependent cause of hypercortisolemia originating from the pituitary gland. The patient underwent an unsuccessful transsphenoidal surgery and subsequently required medical therapy (ketoconazole) to control her hypercortisolemia.

She reports to your clinic with new-onset headaches and muscle weakness. Her workup reveals severe hypertension and hypokalemia. A further increase in the dose of ketoconazole results in worsening hypertension and hypokalemia. What is the likely cause of her presentation?

A 23-year-old Caucasian woman presents with a six-month history of progressive weight gain and amenorrhea. Her physical examination is significant for moderate hirsutism, facial plethora, and multiple violaceous striae involving the abdomen. She is noted to have significant hyperpigmentation of her palmar creases. A 1mg overnight dexamethasone suppression test was significant for a post suppression cortisol level of 3 mcg/dL. What is the most likely diagnosis?

A 23-year-old female with celiac disease presents with a 10-pound unintentional weight loss over four weeks, palpitations, and diarrhea. She reports anterior neck pain. She is noted to have anterior neck pain on the physical exam. An I-123 radioactive iodine scan was low. ESR was elevated at 120mm/hr. Her TSH was suppressed at <0.01 (reference range 0.5—4.1 mIU/L) with a free T4 of 3.7 (reference range 0.7-1.5 ng/dL) and free T3 of 12.4 (reference range 2.0-4.1 ng/dL. Which of the following regarding the patient’s prognosis is accurate?

A 23-year-old obese woman with polycystic ovary syndrome is referred to the reproductive endocrinology clinic. She is being scheduled for an assisted reproductive procedure. The patient requests metformin be added to her treatment regimen. Which of these statements is true regarding the role of metformin in anovulatory infertility.

A 24-year-old woman presents with new-onset galactorrhea and a 3-month history of amenorrhea. Her urine pregnancy screen is negative. Serum prolactin level of 98 ng/mL (4-30 ng/mL), normal serum IGF-1, normal ACTH and 8 AM cortisol, normal free T4. A dedicated pituitary MRI showed a 4 mm adenoma. Which of the following management timelines is incorrect?

A 26-year-old female with Graves disease, well-controlled on thionamide therapy. Which of the following is not a good predictor of long-term remission after a drug holiday?

A 32-year-old female with a 6-month history of amenorrhea is noted to have a diagnostic Cushingoid body habitus during her physical examination. Her urine pregnancy test is negative. A 1 mg overnight dexamethasone suppression test is significant for a post-suppression cortisol level of 4 mcg/dL. 24-hour urinary free cortisol and late-night salivary cortisol levels were 2 and 3 times above the upper limit of normal, respectively. Plasma ACTH is elevated at baseline. A dedicated pituitary MRI showed a 3mm sellar lesion. What is the best next step in the evaluation of this patient?

A 32-year-old man with postoperative hypoparathyroidism reports for his annual check-up. His serum calcium is 6.2 (8.5-10.5 mg/dL. He is symptomatic of hypocalcemia (acral paraesthesias and muscle cramps). He endorses compliance with calcitriol 2mcg daily and calcium 6000mg daily. His 24hour urine calcium is elevated at 623mg/24hrs (normal reference <325mg per 24hours). 25-OH vitamin D is 43 (30-80). You elect to start him on recombinant human parathyroid hormone rhPTH(1-84). How is this form of exogenous parathyroid hormone different from PTH(1-34), the form utilized in the treatment of osteoporosis.

A 34-year-old woman with oligomenorrhea is diagnosed with polycystic ovary syndrome. She is prescribed spironolactone and oral contraceptives due to severe acne and hirsutism. Which of these effects can be attributed to the mechanism of action of spironolactone?

A 23-year-old Caucasian woman presents with a six-month history of progressive weight gain and amenorrhea. Her physical examination is significant for moderate hirsutism, facial plethora, and multiple violaceous striae involving the abdomen. She is noted to have significant hyperpigmentation of her palmar creases. A 1mg overnight dexamethasone suppression test was significant for a post suppression cortisol level of 7 mcg/dL. Which of the following interpretations of the dexamethasone suppression test in the evaluation of endogenous hypercortisolemia is true?

A 43-year-old man presents with an 8-month history of fatigue, lack of libido, and increasing central belly fat. He has a remote history of brain radiotherapy 15 years earlier. Physical examination was significant for truncated eyebrows, dry, doughy skin, and delayed relaxation phase of his deep tendon reflexes at the ankles. Serum testosterone (measured at 9 am, fasting) was 50 ng/dL (250-800 ng/dL), low LH, low FSH, TSH of 1.2 (reference range 0.5—4.1 mIU/L), normal prolactin and low IGF-1 (age and gender-matched). You performed a random cortrosyn stimulation test after his early morning cortisol returned borderline low. His post-stimulation cortisol level was, however, appropriate after 30 minutes. What is the next best step in the evaluation of this patient?

A 45-year-old female is diagnosed with a 3.5cm left adrenal incidentaloma. The lesion has a low attenuation value on non-contrast CT consistent with a benign adenoma. She has no significant past medical history. Her blood pressure is 116/62mmHg. Her serum potassium is 4.0. What is the next best step in the management of this patient?

A 45-year-old is diagnosed with an invasive macroprolactinoma and is started on medical treatment. He is subsequently diagnosed with compulsive gambling and sexual inappropriateness. What is the most likely cause?

A 45-year-old man presents with a 5-year history of poor libido. He is noted to have significant acral enlargement, prognathism, and bilateral carpal tunnel syndrome. IGF-1 is noted to be elevated up to 2 times the upper limit of normal. You perform an oral glucose tolerance test with 75grams of anhydrous glucose. His nadir serum growth hormone is inappropriately elevated at 2.3 ng/dL after two hours. The patient is diagnosed with a 12mm growth hormone-secreting macroadenoma and undergoes transsphenoidal surgery. He, unfortunately, has progressive persistent disease post-surgery and is started on appropriate medical therapy. The patient, however, develops significant elevation in serum transaminases within a few weeks of treatment. Which of the following medications is associated with this side effect?

A 46-year-old Caucasian woman presents with a six-month history of progressive weight gain. Her physical examination is significant for moderate hirsutism, facial plethora, and multiple violaceous striae involving the abdomen. She is also noted to have significant hyperpigmentation of her palmar creases. A 1mg overnight dexamethasone suppression test was significant for a post suppression cortisol level of 8 mcg/dL. Pituitary MRI showed a 1.6 cm adenoma on the right side of the pituitary gland. Inferior petrosal sinus sampling (IPSS) confirmed the diagnosis of an ACTH-dependent cause of hypercortisolemia originating from the pituitary gland. The patient underwent an unsuccessful transsphenoidal surgery and subsequently required medical therapy (mifepristone) to control her symptoms.

She reports to your clinic with new-onset fatigue, nausea, and colicky abdominal pain. She is hypotensive, and further workup reveals a random serum cortisol level of 43 (5-15 mcg/dL). What is the likely cause of her presentation?

A 46-year-old man presented with an 8-year history of poor libido and a 1-year history of migraine headaches with visual symptoms. He also reported increased fatigue and profuse sweating. A “photograph biopsy” was significant for a marked change in his facial features over the past ten years. Physical examination was significant for increased interdental distance. He had significant acanthosis nigricans and multiple acrochordons involving flexural areas. Visual field testing suggested bitemporal hemianopsia. A contrast-enhanced T1 weighted MRI showed a pituitary adenoma measuring 2x3x2.5cm with suprasellar extension and chiasmal optic impingement.

Serum IGF-1 1256 ng/mL (Upper limit of normal for age and gender being <315 ng/Ml). A mid-morning random growth hormone level of 45 ng/mL (normal <4 ng/mL. A 75gram oral glucose tolerance test was significant for GH levels of 35, 28.9, 23.4, 22.1, and 20.7 ng/mL at baseline, 30,60,90, and 120 minutes, respectively. His other pituitary hormonal axes were intact during preoperative workup. He subsequently underwent transsphenoidal surgery. The pathology report reported a cytokeratin staining pattern in round perinuclear structures (fibrous bodies) consistent with a sparsely granulated somatotroph adenoma.

A 75-gram oral glucose tolerance test was repeated a week after surgery. Post suppression growth hormone levels were 2.1, 1.1, 1, 0.9, 0.8 and 0.9 at baseline, 30, 60, 90 and 120 minutes respectively. The detection limit of the growth hormone assay for this laboratory is 0.01 ng/mL.

Which of the following statements is true

A 47-year-old woman with a history of celiac disease and post-traumatic stress disorder presents with a six-month history of persistent hyperthyroidism of unclear etiology. She has a small and non-tender thyroid gland on physical examination. Which of the following investigations will be most helpful in distinguishing subacute lymphocytic (painless) thyroiditis from factitious consumption of thyroid hormone by the patient?

A 52-year-old postmenopausal woman presents with a 12-month history of distressing vasomotor symptoms. She has a history of total abdominal hysterectomy. Your patient has completed a recent google search regarding the risks and benefits of menopausal hormone therapy. Which of the following statements made by the patient is accurate?

A 52-year-old woman presents with a 2-year history of progressive weight gain. Her physical examination for a BMI of 38 kg/m2 and a supraclavicular fat pad. She has a low baseline DHEA sulfate and ACTH. A 1mg overnight dexamethasone suppression test was significant for a post suppression cortisol level of 5.2 mcg/dL. What is the most likely diagnosis?

A 54-year-old woman with hypertension, atrial fibrillation, coronary artery disease (status post two coronary stent placements), diabetes mellitus, and a recent distal radial fracture presents to your office on account of elevated serum TSH in the setting of elevated free T4 and free T3. A pituitary MRI was normal with an elevated serum alpha subunit of pituitary glycoprotein. What is the best next step in the evaluation of this patient?

A 55-year-old female is diagnosed with a 2cm right adrenal incidentaloma. The lesion has a low attenuation value on non-contrast CT consistent with a benign adenoma. She has no significant past medical history. Screening tests of hormonal hypersecretion returned reassuringly normal. Which of the following scenarios is not an indication for referral to surgery?

A 69-year-old man presents with a 5-year history of poor libido. He is noted to have significant acral enlargement, prognathism, and bilateral carpal tunnel syndrome. IGF-1 is noted to be elevated up to 2 times the upper limit of normal. You perform an oral glucose tolerance test with 75grams of anhydrous glucose. His nadir serum growth hormone is inappropriately elevated at 2.3 ng/dL after two hours. The patient is diagnosed with a 12mm growth hormone-secreting macroadenoma and undergoes transsphenoidal surgery. He, unfortunately, has progressive persistent disease post-surgery and is started on appropriate medical therapy. The patient, however, develops severe hyperglycemia within a few weeks of treatment. Which of the following medications is the most likely cause?

A patient presents with recent onset fatigue and general malaise. She is noted to have a normal TSH, low free T3 and a low free T4. Her reverse T3 level is high. What is her most likely diagnosis?

A patient with newly diagnosed type 2 diabetes should participate in a comprehensive diabetes self-management education program that includes all of the following EXCEPT:

Which of the following is NOT a goal of medical nutrition therapy (MNT) in patients with type 2 diabetes?

Which of the following medication classes promotes weight loss and helps prevent weight gain due to other glucose-lowering pharmacotherapies in patients with type 2 diabetes?

What is the recommended amount of moderate-intensity aerobic activity for adults with diabetes per week?

Which of the following is a reasonable glycemic management target for most patients with type 2 diabetes?

Which intervention has been shown to result in diabetes remission for some patients with type 2 diabetes?

In addition to glycemic management, which factor should be a top priority for patients with type 2 diabetes?

What type of exercise is recommended for adults with type 2 diabetes to decrease sedentary time?

A 52-year-old man with a BMI of 28 kg/m2 is diagnosed with type 2 diabetes. His A1C is 8.2%. What is the recommended initial pharmacologic therapy for this patient?

In the Look AHEAD trial, which of the following was a primary outcome?

Which of the following is a contraindication for metformin use in patients with type 2 diabetes?

In patients with type 2 diabetes, what is the main goal of intensive lifestyle modification interventions?

Which of the following noncardiac benefits was observed in the Look AHEAD trial's intensive lifestyle intervention group?

In patients with type 2 diabetes, what is a reasonable target for glycated hemoglobin (A1C) levels?

Which medication is generally suggested as the initial therapy for most patients with type 2 diabetes?

When is metformin contraindicated in patients with type 2 diabetes?

For patients with type 2 diabetes and cardiorenal comorbidities who cannot take metformin, which class of medications is suggested?

A 45-year-old patient is newly diagnosed with type 2 diabetes and has an A1C of 7.8%. What initial pharmacologic therapy do you recommend?

A patient with type 2 diabetes has an A1C of 7.3% and is highly motivated to make lifestyle changes. How long should they be given to try lifestyle modification before initiating pharmacologic therapy?

In patients with type 2 diabetes and established cardiovascular or kidney disease, which class of medications has demonstrated cardiovascular and kidney benefits?

Which medication is not recommended for initiation in patients with type 2 diabetes and an eGFR <30 to 45 mL/min/1.73 m2 due to diminishing effects with lower eGFR?

A patient with type 2 diabetes has not achieved their individualized glycemic treatment goal within three months with metformin plus lifestyle intervention. What is the most appropriate next step according to the ADA and EASD consensus guideline?

Which of the following is a conventional glucose goal for patients with type 2 diabetes aiming for an A1C goal <7 percent?

Which of the following factors can contribute to worsening glycemia in patients with type 2 diabetes?

A 55-year-old patient with type 2 diabetes and an A1C >9 percent presents with persistent symptoms of hyperglycemia. Which of the following medications is suggested as a second-line treatment in this case?

Which of the following insulin types has been commonly used at bedtime to supplement oral hypoglycemic drug therapy?

In a patient with type 2 diabetes and established ASCVD, which medication is typically preferred as an add-on therapy to metformin?

For patients with type 2 diabetes and heart failure or diabetic kidney disease, which medication is the recommended add-on therapy to metformin?

A 52-year-old patient with type 2 diabetes and an eGFR of 40 mL/min/1.73 m2 is not reaching glycemic goals with metformin alone. Which of the following agents would be an appropriate alternative or addition to their treatment plan?

In which patient group should the use of SGLT2 inhibitors be avoided?

Which medication should be used cautiously in patients with type 2 diabetes and advanced chronic kidney disease (eGFR < 30 mL/min/1.73 m2)?

Based on the GRADE trial results, which medication had the lowest proportion of individuals with weight gain of ≥10 percent?

Which medication class is associated with a low risk of hypoglycemia and may be preferable for patients who need to avoid hypoglycemia?

A 55-year-old patient with type 2 diabetes has an A1C of 8.5% despite being on metformin and a sulfonylurea. What is the most appropriate next step in management?

Which medication class may decrease insulin dose requirements when added to a patient's regimen, but requires close follow-up and insulin dose adjustment to reduce the risk of hypoglycemia?

In patients with type 2 diabetes inadequately managed with two agents, what is one potential advantage of switching to insulin rather than adding a third oral or injectable agent?

When initiating insulin therapy in a patient with type 2 diabetes, which medication is usually discontinued due to reduced efficacy and adverse effects?

A patient with type 2 diabetes and persistent hyperglycemia on metformin monotherapy has an A1C of 8.5% and established ASCVD. What would be the most appropriate second agent to add to their treatment plan?

Which of the following medication classes should not be combined in the treatment of type 2 diabetes?

A patient with type 2 diabetes and A1C >9 percent without catabolic symptoms or existing cardiac disease is considering a second agent. Which medication may be favored when weight loss is important?

For patients with type 2 diabetes and obesity class II or III, what treatment option is suggested in addition to lifestyle measures and optimal medical therapy?

A 35-year-old woman presents with a 9-month history of irregular menstrual cycles and occasional milky discharge from her breasts. She also reports intermittent headaches and slightly blurred vision. Her past medical history includes hypothyroidism, well-controlled on levothyroxine 75 mcg daily. On examination, blood pressure is 118/76 mm Hg, heart rate is 78/min, and there are no focal neurological deficits. Laboratory studies show:Serum prolactin: 98 ng/mL (normal: 5–20 ng/mL)TSH: 1.3 mIU/L (reference range: 0.5–4.5 mIU/L)Free T4: 1.1 ng/dL (reference range: 0.8–1.8 ng/dL)Which of the following is the best next step in management?

A 29-year-old man presents with decreased libido, erectile dysfunction, and chronic fatigue for the past eight months. He has no significant past medical history. On physical exam, he has mild bilateral gynecomastia. Vital signs are stable. Laboratory results show:Serum prolactin: 65 ng/mL (normal: <20 ng/mL)Total testosterone: 200 ng/dL (reference range: 280–800 ng/dL)TSH: 2.1 mIU/L (reference range: 0.5–4.5 mIU/L)Which of the following is the most appropriate next step in management?

A 42-year-old woman with a known microprolactinoma (6 mm) returns for follow-up. She has been on bromocriptine 2.5 mg twice daily for four months. She complains of persistent nausea and occasional dizziness. Despite treatment, her serum prolactin is 80 ng/mL (previously 90 ng/mL). She continues to have amenorrhea and intermittent galactorrhea. MRI of the sella turcica shows stable tumor size with no suprasellar extension.Which of the following is the best next step in management?

A 39-year-old woman with a macroprolactinoma (1.3 cm) returns for evaluation. She has been on cabergoline 0.5 mg twice weekly for six months. Her headaches and breast discharge have improved, but her menses remain infrequent. Recent labs show a serum prolactin level of 30 ng/mL (previously 120 ng/mL). Follow-up MRI shows the tumor is now 1.1 cm with no suprasellar extension. She reports no visual field disturbances.Which of the following is the most appropriate next step in management?

A 27-year-old woman who is 3 months postpartum presents with persistent galactorrhea and absent menses since childbirth. She breastfed for only 2 weeks and then switched to formula feeding. Her past medical history is unremarkable. Laboratory results show:Serum prolactin: 85 ng/mL (normal: 5–20 ng/mL)TSH: 1.6 mIU/L (reference range: 0.5–4.5 mIU/L)Serum beta-hCG: negativePhysical examination reveals no visual field deficits. She denies headache or other neurologic symptoms.Which of the following is the best next step in management?

A 52-year-old man presents with abrupt onset of severe headache and blurry peripheral vision for the past 24 hours. He has had long-standing elevated prolactin levels (500–800 ng/mL range) but declined any treatment. Current exam reveals bitemporal hemianopsia and a blood pressure of 140/88 mm Hg. An urgent MRI of the brain shows a 2.5-cm pituitary lesion with evidence of hemorrhage.Which of the following is the best next step in management?

A 34-year-old woman presents with a 5-month history of amenorrhea and fatigue. She also mentions occasional nipple discharge. Review of systems reveals that she started a new antipsychotic medication (risperidone) 6 months ago. Laboratory studies show:Serum prolactin: 50 ng/mL (normal: 5–20 ng/mL)Serum beta-hCG: negativeTSH: 1.8 mIU/L (0.5–4.5 mIU/L)She has no headaches or vision changes. Physical exam is otherwise unremarkable.Which of the following is the most appropriate initial approach to manage her hyperprolactinemia?

A 39-year-old man presents with progressive changes in facial appearance and an increase in his shoe and ring sizes over the past 2 years. He also reports fatigue, joint pain, and occasional headaches. On examination, he has coarse facial features, mild macroglossia, and enlarged hands (difficult ring removal). Blood pressure is 150/88 mm Hg. Laboratory testing reveals:Fasting plasma glucose: 116 mg/dL (reference: 70–99 mg/dL)IGF-1: 780 ng/mL (reference: 100–300 ng/mL, age-adjusted)Which of the following is the most appropriate next step in establishing the diagnosis?

A 45-year-old woman with confirmed acromegaly due to a 1.2 cm GH-secreting pituitary adenoma undergoes transsphenoidal surgery. Three months postoperatively, her serum IGF-1 remains elevated at 450 ng/mL (reference: 100–300 ng/mL, age-adjusted). A repeat pituitary MRI shows a small residual intrasellar lesion. She complains of persistent sweating, acral enlargement, and fatigue.Which of the following is the best next step in her management?

A 28-year-old woman presents with a 1-year history of progressive weight gain, irregular menses, easy bruising, and fatigue. Examination shows centripetal obesity, purplish abdominal striae, mild proximal muscle weakness, and a round “moon” face. Her blood pressure is 150/90 mm Hg. Laboratory tests reveal:Serum cortisol after 1 mg overnight dexamethasone suppression: 12 µg/dL (reference: <1.8 µg/dL)Serum ACTH: 60 pg/mL (reference: 10–60 pg/mL)Which of the following is the best next step in distinguishing between pituitary (Cushing’s disease) and ectopic sources of ACTH?

A 35-year-old man is diagnosed with persistent Cushing’s disease (CD) despite prior transsphenoidal resection of a pituitary microadenoma. He has persistent hypertension, hyperglycemia, and elevated 24-hour urinary free cortisol. A repeat MRI shows no visible remnant tumor. He prefers to avoid radiation if possible. Which of the following is the most appropriate next step?

A 42-year-old man is being evaluated for persistent acromegaly despite prior transsphenoidal resection of a GH-secreting pituitary macroadenoma. His serum IGF-1 remains elevated (3.0 × upper limit of normal) and repeat MRI shows a small suprasellar extension. He complains of persistent arthralgias and headaches.Which of the following is the most appropriate next step in management?

A 35-year-old woman presents with mild hypercortisolism that has fluctuated over several months. She reports episodes of facial rounding, weight gain, and menstrual irregularities that spontaneously improve for weeks at a time. Recent labs show:24-hour urinary free cortisol (UFC): intermittently elevatedLate-night salivary cortisol: elevated on two tests, normal on two other testsSerum ACTH: high-normalWhich of the following is the most likely explanation for these findings?

A 50-year-old man with recurrent Cushing’s disease underwent transsphenoidal resection twice, and pituitary MRI still shows a small remnant lesion. Over the past year, his hypercortisolism has been controlled with ketoconazole 600 mg/day, but now he reports severe fatigue, nausea, and elevated liver enzymes. Laboratory tests show:AST: 150 U/L (reference: <40 U/L)ALT: 162 U/L (reference: <40 U/L)Bilirubin: 3 mg/dL (reference: 0.3–1.2 mg/dL)The patient has persistent hyperglycemia and hypertension.He wishes to stop ketoconazole due to side effects. Which of the following is the most appropriate next step?

A 48-year-old man presents with chronic headaches and progressive loss of peripheral vision over the past 6 months. MRI reveals a 2.5 cm sellar mass extending into the suprasellar region without evidence of hormone hypersecretion on preliminary labs. Which of the following findings would most strongly suggest that this is a non-functioning pituitary adenoma?

A 55-year-old woman is diagnosed with a 1.8 cm non-functioning pituitary macroadenoma. She has mild headaches but no visual deficits and normal pituitary function. Which of the following is the best initial management approach?

A 62-year-old man underwent transsphenoidal surgery for a large non-functioning pituitary macroadenoma that was causing bitemporal hemianopsia. Postoperatively, imaging shows a small residual tumor, and pathology indicates a gonadotroph subtype with a Ki-67 labeling index of 4%. Which of the following is the best statement regarding his prognosis or treatment plan?

A 60-year-old woman presents 10 years after transsphenoidal resection of a non-functioning pituitary macroadenoma. She has been well until recently, when she developed new headaches and mild visual changes. MRI reveals regrowth of the residual tumor with suprasellar extension approaching the optic chiasm. She has stable pituitary hormone function on testing. Which of the following is the most appropriate next step?