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-Endocrine Questions-
Questions 1-5 1. Which of the following hormones is most important at birth for proper brain development? A. T3 B. Growth hormone C. Androgens/Estrogens
2. Destruction of the Zona Fasciculata would preferentially decrease which of the following hormones? A. Estradiol B. Cortisol C. Aldosterone D. Testosterone
3. Where would you most likely find angiotensin receptors? A. Zona Glomerulosa B. Zona Fasciculata C. Zona Retucularis
4. Which of the following is the most common functioning tumor of the pituitary? A. Growth hormone adenoma B. Coricotroph cell adenoma C. Gonoadotroph adenoma D. Prolactinoma
5. Which of the following of the following is not characteristic of chronic primary adrenal insufficiency? A. Hyperkalemia B. Hyponatremia C. Hypertension D. Cortisol deficiency E. Increased ACTH F. Increased renin
Answers for questions 1-5 1. Answer: A Thyroid hormones are present the largest amounts at birth and steadily declines after the first few years of life. Thyroid hormone is required for proper brain development. Without it, stunted physical and mental development will manifest (cretinism). Growth hormone starts out at low levels but rises rapidly to a plateau by age 2. Androgens and estrogens are not present in large amounts until puberty. 2. Answer: B The Zona Glomerulosa produces mineralocorticoids, namely aldosterone. The Zona Fascilulata produces glucocorticoids, namely cortisol. The Zona Reticularis produces testosterone and estradiol. 3. Answer: A The Zona Glomomerulosa produces aldosterone. Since aldosterone is a key player in the renin-angiotensin system, we can expect to find angiotensin receptors in the Zona Glomerulosa. The Zona Fascilulata produces glucocorticoids, namely cortisol. The Zona Reticularis produces testosterone and estradiol. Source: Bockman lecture 8 Archive 2008 23’. 4. Answer: D Prolactinoma is the most common functioning tumor of the pituitary. Features of this tumor include secondary amenorrhea and galactorrhea in women. Feedback inhibition on GnRH would cause reduced levels of FSH and LH. This can be treated with bromocriptine, a dopamine agonist. 5. Answer C : The classic presentation of primary adrenal insufficiency is low Na+, high K+, hypotension (from hypovolemia), and hyperpigmentation. Normally, the Zona Glomerulosa in the adrenal gland produces aldosterone, which increases Na+ reabsorption via action on principal cells mainly in the collecting duct, which increases K+ secretion. As aldosterone production drops, hyponatremia and hyperkalemia are direct results. The loss of Na+ results in a decrease in extracellular volume (hypovolemia), and therefore hypotension. Hyperpigmentation is a result of the increasing ACTH production of the pituitary in response to decreased cortisol. A by-product of ACTH production is melanocyte stimulating hormone (MSH), which increases pigmentation. Finally, the kidneys respond by to the induced hypervolemia by increasing renin.
Questions 6-12 6. Diabetic ketoacidosis results in increased production of all of the following except: A. Beta-hydroxybutyrate B. acetone C. acetoacetate D. alpha-ketoglutarate E. HMG-CoA reductase (3-hydroxy-3-methyl-glutaryl-CoA reductase)
7. Diabetes is the leading cause of all the following except: A. Neuropathy B. End stage renal disease C. Adult onset blindness D. Non-traumatic limb amputation
8. Which of the following promotes insulin secretion? A. Sympathetic stimulation B. Somatostatin C. Glucagon D. Cortisol E. Growth hormone
9. Long term administration of glucocorticoids will result in which two of the following? A. Increased ACTH B. Hypoglycemia C. Hypotension D. Poor wound healing E. Osteoporosis
10. Which of the following circumstances is most favorable to the formation of thyroid hormone (ie: Wolff-Chaikoff effect)? A. Low levels of Iˉ, high levels of tyrosine B. Low levels of Iˉ, low levels of tyrosine C. High levels of Iˉ, high levels of tyrosine D. High levels of Iˉ, low levels of tyrosine
11. The largest amount of hormone produced in the thyroid is made by combining: A. MIT and DIT B. MIT and MIT C. DIT and DIT D. DIT and Iodide
12. A chronic alcoholic presents to the ER with ascites and yellow discoloration of the eyes. What do you expect his thyroid hormone levels to be? A. Increased total thyroid hormone levels, normal free hormone levels B. Increased total thyroid hormone levels, decreased free hormone levels C. Decreased total thyroid hormone levels, normal free hormone levels D. Decreased total thyroid hormone levels, increased free hormone levels.
Answers for questions 6-12 6. Answer: D DKA results in the breakdown of fatty acids and proteins. The final steps involve HMG-CoA breaking down to become acetoacetate, which breaks into acetone and B-hydroxybutyrate. Alpha-ketoglutarate is part of the TCA cycle, which is underutilized in DKA.
7. Answer A : Diabetes is the leading cause of kidney disease, blindness and amputation. While neuropathy is common, diabetes is not the leading cause. Source: American Diabetes Association
8. Answer C: While insulin inhibits glucagon, glucagon actually stimulates insulin secretion (per Dr. Mackin). All the other answers directly oppose insulin secretion. Important stimulators of insulin are glucose, amino acids, parasympathetics, and GLP-1.
9. Answer D & E: Cushing’s syndrome can be primary (ie: adrenal hyperplasia or pharmacologic) or secondary (ie: ACTH producing tumor). Either way, the overproduction of cortisol will induce the characteristic moon facies, truncal obesity, striae, muscle wasting, and buffalo hump. Additional features include impaired immune function, hyperglycemia, hypertention, and osteoporosis, all of which are direct effects of cortisol. The major difference between primary and secondary Cushing’s is that secondary has an increase in ACTH (from a tumor) and primary has a decrease in ACTH (from the negative feedback mechanism of cortisol).
10. Answer A: The Wolff-Chaikoff effect results in a decrease in the products of I2 and tyrosine (ie MIT and DIT) at high levels of Iˉ. Therefore, low levels of Iˉ are required in the presence of tyrosine.
11. Answer C: Thyroxine, called T4, is the major hormone produced by the thyroid. Although triidothyronin, or T3, is more active, it is produced in smaller amounts. Monoiodotyrosine (MIT) is a tyrosine with one Iodide attached, and and diiodotyrosine (DIT) is a tyrosine with two Iodides attached. Making T4 requires the combination of two DIT molecules (2+2=4). T3 is from MIT + DIT.
12. Answer C: In the case of hepatic failure, protein production is down, which leads to a decrease in thryroxine-binding globulin (TBG) production. Therefore the total levels of thyroid hormone should be decreased. There is no reason presented to believe that free hormone levels should be affected. An important cause of increased total thyroid hormone levels is pregnancy. TBG production increases, but once again free hormone levels are normal.
Questions 13-18 13. Which of the following is the most common presentation of posterior pituitary pathology? A. Hypertension B. Excessive lactation C. Polyphagia D. Polyuria
14. Mutation in which subunit of which G protein subunit is likely to cause an increase in cAMP? A. alpha B. bets C. gamma D. delta E. G proteins do not affect cAMP
15. A thin patient presents with diarrhea, insomnia, and claims to always be hot. Lab values are normal, including TSH. Injection of TRH results in an appropriate rise of TSH. Which of the following is excluded as a cause? A. Grave's disease B. Pituitary adenoma C. Thyroid carcinoma D. Hashimoto's thyroiditis
16. When comparing Grave's disease and Hashimoto thyroiditis, which of the following is more indicative of Grave's? A. Lymphoid cell infiltrates B. Women are more affected than men C. Thyroid enlargement D. Increased diffuse radioactive iodine uptake
17. You are managing a type I diabetic patient who recently received a Beta cell transplant. Of the following immunosuppresive agents, which is most dangerous to give to a diabetic? A. Sirolimus B. Tacrolimus C. Prednisone D. Mycophenolic acid (Cellcept)
18. A patient presents with central obesity, buffalo hump, hirsuitism, hyperglycemia, hyperpigmentation, and hypertension. Which of the following is most likely if she has no decrease in cortisol after administration of low dose dexamethasone? A. Pituitary adenoma B. Adrenal adenoma C. Adrenal hyperplasia
Answers for questions 13-18 13. Answer D: The posterior pituitary produces ADH (aka: vasopressin) and oxytocin. A funtional tumor in the posterior pituitary may produce ADH, resulting in oliguria from the hormones action on principal cells in the collecting duct. Another possibility is that the tumor could impinge on the ability to produce ADH, which would result in polyuria. Any tumor in the area of the pituitary could cause bitemporal hemianopsia.
14. Answer A: G proteins are made up of three subunits, alpha, beta, and gamma. The alpha unit carries the enzymatic activity. Therefore, a mutation in the alpha unit could result in overstimulation of adenylate cyclase and an increase in cAMP. In regards to parathyroid function, this cAMP increase would result in an increase in PTH secretion.
15. Answer B: An appropriate rise in TSH implies that the problem is not in the pituitary. Therefore, pituitary adenoma is unlikely.
16. Answer D: Grave's disease has far more thyroid activity than Hashimoto thyroiditis.
17. Answer C. Of these, steroids will have the effect of increasing blood glucose. Clearly, this could make glycemic control problematic.
18. Answer A: The question is tricky because none of these conditions would not be expected to respond to dexamethosone. Normally, the pituitary is suppressed by dopamine. Since dexamethosone is a dopamine agonist, it would be expected to reduce anterior pituitary activity. However, of those listed as answers, only pituitary adenomas respond to dexamethosone, and they only respond at high doses. The only other way to distinguish between these four choices is the presence of ACTH. The trick is that since she is hyperpigmented, the most likely choice is the one associated with the highest levels of ACTH. Pituitary adenoma produces the most ACTH, which results in the concomitant production of MSH, causing hyperpigmentation. We could expect decreased levels of ACTH in the other choices since the increased levels of cortisol would suppress pituitary secretions.
Questions 19-24 19. Glucocorticoids such as cortisol and prednisone are well known for their immunosuppressive properties. Which of the following is most important for this purpose? A. TdT inhibition B. IL-2 inhibition C. Stimulation of phospholipase A2 D. Inhibition of ICAM E. Inhibition of VLA-1
20. A patient with type I diabetes injects twice the normal amount of insulin. Which of the following is not likely to happen? A. Decreased amino acids in the blood B. Increase in glycogen stores in liver C. Plasma glucose less than 50 pg/ml D. Hypokalemia E. Increase in C peptide
21. Which of the following synthetic thyroid medications would be expected to have the longest half life? A. Levothyroxine B. Liotrix C. Liothyronine
22. Which of the following is the most likely place to have accessory thyroid tissue? A. Greater cornu of the hyoid bone (the greater cornu is posterior) B. Palatine tonsils C. Foramen cecum D. Thymus
23. Which of the following is not a product of preproopiomelanocortin (POMC)? A. alpha-MSH B. beta-MSH C. ACTH D. IGF-1 E. beta-LPH
24. Which of the following is not a glycoprotein secreted by the anterior pituitary? A. Luteinizing hormone (LH) B. Follicle stimulating hormone (FSH) C. Thyroid releasing hormone (TRH) D. Actually, all of the above are glycoproteins secreted by the anterior pituitary
Answers for questions 19-24 19. Answer B: Glucocorticoids inhibit IL-2, which is a cytokine that promotes the proliferation of lymphocytes. Answer D may be true, but to a much lesser degree than answer B. Here's a study from Johns Hopkins in 1999 that claims "no inhibition of ICAM-1 expression" for commonly used inhaled glucocorticoids <http://ajrcmb.atsjournals.org/cgi/content/abstract/ 20/4/643>. Other studies do find a reduction in ICAM. Take-home message: the main mechanism of immunosuppression from glucocorticoids is reduction in IL-2.
20. Answer E: Since the insulin is injected, there will be no increase in C peptide. C peptide only increases when insulin is made in the body, since it is cleaved off of the proinsulin molecule to leave mature insulin. Therefore, the amount of C protein in the body is proportional to the amount of endogenous insulin produced.
21. Answer A: Levothyroxine is pure T4, liothyronine is pure T3, and liotrix is a combination of T4 and T3 in a 4:1 ratio. Liothyronine (T3) is more active than T4 because more of it is bound to albumin. Since albumin has a low affinity for it, T3 is more likely to dissociate (and therefore be active). Levothyroxine is more likely to bind to TBG and TBPA, and therefore less likely to be dissociated. For this reason, levothyroxine will remain in the blood for longer than the more active liothyronine.
22. Answer C: The thyroid gland arises from the 3rd and 4th pharyngeal arches and pouches. It descends from the foramen cecum (the base of the tongue) and continues anterior to the foregut until it stops below the larynx. An abscence of the 3rd and 4th pharyngeal arches will result in DiGeorge Syndrome, which is almost always associated with deletion in chromosome 22. "A" is incorrect because the greater cornu is a posterior projection of the hyoid, and "B" is incorrect because the palatine tonsils are lateral to the foramen cecum. "D" is incorrect because the thymus is below the thyroid. Anywhere below the foramen cecum, above the thymus, and on the anterior aspect of the trachea is a reasonable answer.
23. Answer D: POMC is a large mRNA made in the anterior pituitary which is cut to make corticotropin related peptides: alpha-,beta-, and gamma-MSH (melanocyte stimulating hormone), ACTH (which stimulates the adrenal cortex), and LPH (which is poorly understood). IGF-1 is the only answer not produced by POMC. In addition to corticotropin related peptides, the anterior pituitary also produces somatomammotropins: GH (growth hormone) and PRL (prolactin). GH works in part by inducing IGF-1 production in the liver. PRL is a trigger of milk production. Finally, the anterior pituitary produces glycoproteins: LH (luteinizing hormone), FSH (follicle stimulating hormone), and TSH (thryroid stimulating hormone.
24. Answer C: Thyrotropin releasing hormone (TRH) is secreted by the hypothalamus (not the anterior pituitary), and it regulates the release of TSH. Thyroid stimulating hormone (TSH) is from the anterior pituitary, and is causes the thyroid to produce thryroid hormone (T4 and T3). The thyroid produces more T4, but T3 has ~4x more activity.
Questions 25-29 25. You are doing a western blot to determine vasopressin levels in a mouse. You do not have an anti-vasopressin antibody. Considering the proteins bound to vasopressin, which of the following would be an appropriate substitute antibody and location of the fluorescence on your blot? A. anti-neurophysin I, fluorescence near 100 amino acid proteins B. anti-neurophysin I, fluorescence near 10 amino acid proteins C. anti-neurophysin II, fluorescence near 100 amino acid proteins D. anti-neurophysin II, fluorescence near 10 amino acid proteins E. anti-oxytocin, fluorescence near 10 amino acid proteins
26. Which of the following hormones secreted by the pituitary is correctly paired with an appropriate regulatory hormone from the hypothalamus? A. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) B. Growth hormone (GH) and Somatostatin (GIH) C. Thyroid stimulating hormone (TSH) and corticotropin releasing hormone (CRH) D. Gonadotropin releasing hormone (GnRH) and corticotropin releasing hormone (CRH) E. Prolactin (PRL) and serotonin (5-HT)
27. Which of the following stimulates growth hormone release? A. protein B. fatty acids C. glucose D. REM sleep E. cortisol
28. Which is not a feature associated with papillary carcinoma? A. Lymphatic metastasis B. Psammoma bodies C. Hypochromic nuclei D. "Coffee bean" nuclear grooves E. RET/PTC gene in ~25% of cases F. Actually, all of the above are true
29. Which of the following thyroid carcinomas has the overall best prognosis? Which has the worst? A. Anaplastic B. Follicular C. Medullary D. Papillary
Answers for questions 25-29 25. Answer C: Vasopressin is a 9 amino acid protein produced in the posterior pituitary and is secreted with neurophysin II (and also a signal peptide and glycopeptide). Therefore, an anti neurophysin II antibody would likely be a good substitute for a vasopressin antibody. Knowing that vasopressin is packaged with other proteins makes fluorescence near 100 amino acid proteins a reasonable answer. Oxytocin is also produced in the posterior pituitary and is secreted with neurophysin I. There is no reason to believe that levels of oxytocin and vasopressin are linked, so E is an incorrect answer.
26. Answer B: Growth hormone is inhibited
by the release of somatostatin and is produced in response to growth
hormone releasing hormone (GH-RH). LH and FSH are regulated by
GnRH, TSH is regulated by TRH, PRL is regulated by dopamine, and ACTH is
regulated by CRH. | |||||||||||||||||||||
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27. Answer A: Growth hormone affects metabolism in many ways. It
causes the release of fatty acids from adipose tissue and hepatic
release of glucose. These are both used as feedback inhibitors of
GH. GH has anabolic properties that result in the use of protein.
Therefore, high levels of protein promote GH release. D is a
plausible answer since sleep does increase GH, but REM sleep
specifically decreases GH. E is incorrect because the actions of
cortisol largely oppose GH. For example, cortisol results in
decreased muscle mass, truncal obesity, and hyperglycemia.
Finally, it is important to note that insulin will quickly raise GH and
cortisol levels. This can test for secondary adrenal
insufficiency. 28. Answer F: Women are 2 to 3 times more likely to be affected than men. Psammoma bodies are a common feature, as are hypochromic nuclei (so-called "Orphan Annie Eyes"). The RET/PTC gene is the recombination of the tyrosine kinase domain of the RET proto-oncogene on chromosome 10. Additional features of papillary carcinoma are that it has an excellent prognosis (90% 20 year survival), and lymphatic spread, which does not increase the stage of the cancer. 29. Answer D: Papillary carcinoma has a 90% 20 year survival. Papillary carcinoma is also the most common; medullary is the least common. Answer A: Anaplastic carcinoma has the worst prognosis.
Questions 30-35 30. The adrenal medulla is innervated primarily by the: A. lumoringuinal n. B. aortic plexus C. splanchnic n. D. superior mesenteric plexus E. vagus n.
31. Which is of the following are treated with glucocorticoids? A. proteinuria > 3.5g per day B. sarcoidosis C. SLE D. 12 week premature baby E. organ transplant F. All of the above
32. If glucocorticoids are to be used indefinitely, which of the following is not an appropriate adjustment to the patient's diet/lifestyle? A. decrease potassium B. decrease sodium C. increase protein intake D. mild to moderate exercise
33. Which of the following conditions/treatments will likely result in the highest plasma ACTH levels? A. Adrenal adenoma B. Paraneoplasic ACTH secretion C. Adrenal hyperplasia D. Cushings' Disease E. Prednisone
34. Which of the following conditions can be suppressed by administration of dexamethasone (a dopamine agonist)? A. Adrenal adenoma B. Paraneoplasic ACTH secretion C. Adrenal hyperplasia D. Cushings' Disease E. Adrenal carcinoma
35. Which of the following will increase (parathyroid hormone) PTH? A. increased activation of phospholipase C in a chief cell B. acidemia C. decreased plasma albumin D. alkalemia E. increased plasma Ca+2
Answers to questions 30-35 30. Answer C: The adrenal medulla is innervated by the preganglionic splanchnic nerve. The lumboinguinal nerve supplies skin on the upper thigh, and is too low to innervate the adrenal medulla.
31. Answer F: Nephrotic syndrome is defined as proteinuria >3.5g per day. It is associate with hyperlipidemia, edema, and hypoalbuminemia. It is often treated with steroids, so A is correct. B is correct because babies only start making surfactant at around 28 weeks, and glucocorticoids stimulate its production. B, C and E area all conditions that require immunosuppression.
32. Answer A: Prolonged use of glucocorticoids results in Cushing syndrome, which is characterized in part by hyperglycemia, sodium retention, hypertension, osteoporosis, and hypokalemia. "A" is the correct answer because patients with Cushing syndrome need increased potassium intake (more bananas, potatoes, beans, etc.).
33. Answer B: Ectopic ACTH syndrome will produce the largest amounts of ACTH. Cushing's disease (answer D) will also result in increased ACTH secretion, but not nearly as much. Answers A, B, and E will all inhibit production of ACTH in the pituitary.
34. Answer D: Tumors don't like to be told what to do.
35. Answer D: The calcium sensing receptor in the parathyroid chief cell releases PTH in response to low free ionic calcium via a G protein. The G protein promotes cAMP to increase PTH secretion and it promotes phospholipase C to reduce PTH secretion. Knowing these facts, A and E are incorrect. C is incorrect because a decrease in plasma albumin implies that less calcium is carried in a non-ionic state by albumin. B in incorrect because if pH is lowered, there are more H+ ions to block calcium from binding to albumin. Therefore, free ionic calcium in the plasma increases and PTH secretion decreases. Conversely, in an alkalemic state, there is more opportunity for calcium to bind to albumin, reducing plasma levels, and PTH is secreted. Therefore D is correct.
Questions 36-40 36. Which organ is the site of production of biologically active vitamin D3? A. skin B. liver C. kidney D. pancreas
37. Bone matrix is mainly composed of: A. type I collagen B. type IV collagen C. hydroxyapatite D. Ca3(PO4)2
38. Regulation of thyroid hormone occurs both at the level of the hypothalamus and the pituitary. What is the primary feedback mechanism? A. T3 in the anterior pituitary B. T4 in the anterior pituitary C. T3 in the hypothalamus D. T4 in the hypothalamus
39. Which is not a feature of hyperthyroidism? A. arrhythmias B. emotional instability C. delayed epiphyseal closure D. heat intolerance E. hyperreflexia
40. Which synthetic thyroid medication should you prescribe to a patient who often forgets to take his medication? A. Levothyroxine B. Listhyronine C. Liotrix
Answers to question 36-40 36: Answer C: Vitamin D3 is produced by the photoconversion of 7-dehydrocholestrol (7-DHC) in keratinocytes. Next 7-DHC it is converted to 25-hydroxyvitamin D3 in the ER of hepatocytes in the liver. Vit D3 does not become biologically active until it reaches the proximal tubule in a nephron where it is converted to 1,25-dihydroxyvitamin D3.
37. Answer A: pure memorization, but very testable
38. Answer A: pure memorization, but very testable
39. Answer C: Most of the features of hyperthyroidism are obvious. Everything is turned up: increased metabolism, awareness, etc. Hypothyroidism is the opposite. However, a less obvious characteristic of hypothyroidism is a delay in epiphyseal closure.
40. Answer A: Levothyroxine is pure T4, which means that it will be converted to T3 and will have the longest half life. Lesthyronin is pure T3 and will be the shortest acting. Liotrix is a mixture of T4 and T3, so it will have a half life between the others. As you might expect, levothyroxine is the most often used thyroid hormone.
Questions 41-45 41. Which approach to thyroid cancer is least likely to have a recurrence? A. No adjunctive medical therapy B. Radioactive I131 C. External radiation and thyroid hormone D. Thyroid hormone
42. Type I Diabetes is an autoimmune disease against the beta cell in the pancreas. Which of the following is least likely to be a target of autoantibodies in this disease? A. Insulin B. GAD65 (Glutamic acid decarboxylase) C. IA-2 (Insulinoma associated protein) D. C protein
43. Current American Diabetes Association recommendations for exercise in a diabetic patient include: A. 30 minutes of moderate exercise per day and resistance training 3 times per week B. 60 minutes of intense aerobic activity per week C. 150 minutes of moderate aerobic activity per week and resistance training 3 times per week D. at least 4 hours of mild aerobic activity per week E. there is no current standard for exercise in a diabetic patient
44. According to ADA recommendations, which of the following diabetic patients should be prescribed a statin? A. 40 year old male, HDL 40, LDL 140, BP 140/90 B. 12 year old male, HDL 50, LDL 170, BP 120/80 C. 35 year old female, HDL 40, LDL 120, BP 140/90 D. 9 year old male, HDL 50, LDL 190, BP 130/90 E. 50 year old male, HDL 40, LDL 150, BP 150/90
45. Actions of parathyroid on calcium include all of the following except: A. increasing gastrointestinal absorption B. increasing phosphate excretion C. increases production of biologically active vitamin D D. increases renal excretion of calcium E. activates osteoclasts F. actually, all of the above are true
Answers to questions 41-45 41. Answer B: Don't panic if this isn't familiar. It was off of Dr. Gallagher's lecture 15 (I think we skipped it) slide 7.6. Oddly enough, external radiation and thyroid hormone (C) had a worse outcome than no therapy (A).
42. Answer D: The three major targets of antibodies are insulin, GAD65, and IA-2.
43. Answer C: The ADA recommends 150 minutes of moderate aerobic activity per week and resistance training 3 times per week, baring any contraindications.
44. Answer B: The ADA recommends adding an LDL after the age of 10 if LDL > 160 mg/dl. Any patient with cardiovascular disease and diabetes should be on a statin regardless of LDL level (the goal in these patients is LDL<70). All except the highest risk patients have a goal of LDL<100. The patients BP does not have any bearing on statin medication. Patients with a BP > 140/90 should be on and ACE inhibitor or ARB.
45. Answer D Parathyroid hormone acts to increase calcium by actions in the gut, kidney, and bone. In the kidney, calcium reabsorption (not excretion) is increased. Answer E is correct because as osteoclasts are activates, calcium is released from the bone.
Questions 46-50 46. Which of the following protein with endocrine functions is not derived from adipocytes? A. IL-2 B. leptin C. TNF-α D. IL-6
47. Obesity is defined as: A. BMI > 20 B. BMI > 25 C. BMI > 30 D. BMI > 35 E. there is no definition of obesity
48. Sibutramine is a centrally-acting antiobesity drug that makes people feel full sooner. What is its mechanism of action? A. inhibits NE and serotonin reuptake B. pancreatic lipase inhibitor C. dopamine agonist D. inhibits gastrin production
49. Which of the following will not reduce the risk osteoperotic fractures? A. raloxifene in women B. smoking cessation C. physical activity D. increased calcium intake E. all of the above reduce risk
50. Which of the following is the most appropriate treatment in a newly diagnosed 50 year old Type II diabetic patient? A. advise lifestyle changes and prescribe glargine B. advise lifestyle changes and prescribe metformin C. advise lifestyle changes and prescribe metformin and a sulfonylurea D. advise lifestyle changes alone
Answers 46-50 46. Answer A IL-2 plays an important role in development of lymphocytes. It is largely unrelated to adipocytes.
47. Answer C Anyone above a BMI of 25 is considered overweight and over 30 is obese. From there it is divided into classes: Class I (30-35), Class II( 35-40), Class III(40-50), Class IV (50-60), and Class V (>60), or "supersuperobesity".
48. Answer A Since it is centrally acting, only answers A and C are possible. Dopamine agonists, such as bromocriptine, are used to regulate pituitary function. Orlistat is an antiobesity drug that is a lipase inhibitor (answer B).
49. Answer E Risk factors for osteoporosis include Caucasian race, female sex, and dementia.
50. Answer B This is from the ADA's Diabetes Care Dec 2008. The first step should be lifestyle changes and metformin. The next addition should be either basal insulin (glargine) or a sulfonylurea.
Questions 51-55 51. Which of the following best describes the response of a patient with secondary adrenal insufficiency to administration of ACTH? A. little to no response B. hypertensive crisis C. decrease in corticol D. increase in cortisol
52. You suspect that a patient has a disorder of growth hormone (GH) excess. Which of the following would help determine his recent average GH levels? A. IGF-1 B. stomatostatin C. GHRH D. cortisol
53. Long term mortality from hypopituitarism is mostly due to: A. renal failure B. cardiovascular disease C. respiratory failure D. neurologic disease
54. Which of the following is not true of the pituitary? A. the posterior pituitary is smaller than the anterior pituitary B. the pituitary is connected to the hypothalamus by the infundibulum C. the adenohypophysis arises from neural ectoderm D. the pituitary is located below the hypothalamus in the sella tursica.
55. Dysgenesis of the 3rd and 4th pharyngeal arches and pouches is not associated with which of the following? A. microdeletion on chromosome 22 B. immunologic deficiency C. hypocalcemia D. goiter
Answers 51-55 51. Answer D Secondary adrenal insufficiency implies that the problem is not located in the adrenal gland. Therefore, upon stimulation (ie: administration of ACTH), there would be an appropriate response. Primary adrenal insufficiency would result in little to no response.
52. Answer A Growth hormone works via the action of IGF-1. Therefore, levels of IGF-1 should be a good indicator of recent GH levels. Somatostatin inhibits the release of GH from the anterior pituitary, and GHRH stimulates it. Cortisol is largely unrelated to GH.
53. Answer B Straight out of Anderson's key points. The short term risks are as a direct result of cortisol deficiency. However, in the long run, cardiovascular disease prevails.
54. Answer C The posterior pituitary, or the neurohypophysis, arises from neural ectoderm. The anterior pituitary, or the adenohypophysis, comes from pharyngeal ectoderm called Rathke's pouch.
55. Answer D This is describing DiGeorge Syndrome, which is manifested by lack of a thymus and/or parathyroid glands. Almost all cases have a microdeletion of chromosome 22. Immunologic deficiencies are a result of a lack of T cell maturation in the thymus. Hypocalcemia is a result of not producing PTH from absent parathyroid glands. Goiter is enlargement of the thyroid, often from iodine deficiency in other countries.
Questions 56-61 56. Your 60 year old type 1 diabetic patient presents for a routine checkup. His labs results show decreased calcium, increased phosphate, and increased PTH. What is the most likely explanation for this? A. osteosarcoma B. chronic renal disease C. poor diet D. pituitary adenoma
57. A 45 year old man presents with weakness and headaches. His blood pressure is 140/90. Relevant lab findings include serum pH of 7.47, CO2 of 47, HCO3 of 34. Which of the following would be most likely to produce a diagnosis? A. serum sodium and potassium B. bromocriptine challenge C. comparison of renin and aldosterone levels D. water deprivation
58. How would you treat the patient in question 57? A. desmopressin B. SSRI C. ethacrynic acid D. bromocriptine E. spironolactone
59. A newborn child has a jaw malformation develops tetany. What chromosome was most likely involved? A. 8 B. 18 C. 21 D. 22
60. A patient with an overactive pituitary is producing too much ACTH. What enzyme is being stimulated? A. desmolase B. aromatase C. aldosterone synthase D. 5-alpha-reductase E. 11-beta-hydroxylase
61. Two patients were given TRH, and their TSH was measured over the next few hours. Patient A started out with an elevated baseline TSH, which only increased upon TRH administration. Patient B failed to make any detectable TSH. What type of hypothyroidism does each have?
Answers 56-61 56. Answer B Diabetics are prone to renal failure. When this happens, vitamin D is not converted from 25-OH-D3 to 1,25-OH-D3, leading to decreased calcium absorption from the gut as well as hyperphosphatemia. PTH increases in response to the low calcium and increased phosphate.
57. Answer C Conn syndrome, or primary hyperaldosteronism is often caused by aldosterone secreting adrenal adenomas. Key findings are hypertension, metabolic alkalosis, It would manifest with increased aldosterone levels and decreased renin levels. The findings on this patient are a direct result of increased aldosterone levels. Aldosterone stimulates intercalated cells in the collecting duct to secrete H+ ions, which leads to metabolic alkalosis. Since aldosterone also works by increasing the Na+-K+ pump in principle cells of the distal tubule and collecting duct. This causes Na+ reabsorption and K+ secretion. Therefore, in this patient we would expect hypernatremia and hypokalemia. However, there are many other things that could cause this electrolyte imbalance. The serum Na+ and K+ levels would not be diagnostic.
58. Answer E Spironolactone is an aldosterone antagonist and acts as a K-sparing diuretic.
59. Answer D This is a common presentation of DiGeorge syndrome. Underdeveloped parathyroid glands result in tetany from hypocalcemia. The deletion is 22q11. The child will likely have recurrent viral and fungal infections from T cell deficieny.
60. Answer A ACTH promotes desmolase, which converts the conversion of cholesterol to prenenolone. This allows for production of the adrenal steroids.
61. Answer A Patient A has primary hypothyroidism, meaning that the problem is in the thyroid gland itself. He would have a decreased T3 and T4 in his serum, so his TRH and TSH would be elevated in an attempt to make more. Patient B has secondary hypothyroidism, since his pituitary gland is unresponsive to TRH. We would expect him to have low T3, T4, and TSH. He would have an elevated TRH. Know this well as it is likely to show up on boards!
Fact Recall Detection of osteoporosis before a fracture? BMD Most serious potential side effect of metformin? lactic acidosis
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