Endocrine Self-Assessment Program, Questions, Answers, and Discussions

Lisa R Tannock

• Publisher: Endocrine Society
• Year: 2021
• eBook ISBN: 9781879225954
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Medicine

Endocrine Self-Assessment Program (ESAP), Reference Edition 2021 is a self-study resource for physicians and health professionals wanting a self-assessment and broad review of endocrinology. It consists of approximately 120 multiple-choice questions in the areas of endocrinology, diabetes, and metabolism. Correct answers for each question are extensively discussed, with references provided, and the volume also contains a comprehensive syllabus. CME, MOC, online module not included. Updated annually.

QUESTIONS

ENDOCRINE SELF-ASSESSMENT PROGRAM 2021

Part I

1 A 44-year-old woman with type 2 diabetes mellitus treated with insulin presents with worsening hirsutism. She has a history of polycystic ovary syndrome and was previously treated with an oral contraceptive and spironolactone with good control of hyperandrogenism. She stopped taking both of these medications 3 years ago. Type 2 diabetes was diagnosed 7 years ago and was initially treated with metformin. Two years ago, her hemoglobin A_1c level was documented to be 8.3% (67 mmol/mol), and a basal-bolus insulin regimen was started. Over the past year, despite doubling her insulin doses and good adherence to her insulin regimen, her hemoglobin A_1c level has risen to 9.6% (81 mmol/mol). Concomitantly, she has noticed worsening hair growth on her face and chest. In the past 2 months, she has also had worsening lower-extremity edema, amenorrhea, fatigue, and generalized weakness.

On physical examination, her blood pressure is 180/96 mm Hg and pulse rate is 79 beats/min. Her height is 64 in (162.5 cm), and weight is 250 lb (113.4 kg) (BMI = 43 kg/m²). She has moon facies and a dorsocervical hump. There are terminal hairs on her face and chest, mostly removed by shaving. She has thick violaceous striae on her abdomen, proximal muscle weakness, and diffuse ecchymoses scattered over her arms and legs.

Laboratory test results:

Morning serum cortisol following overnight 1-mg dexamethasone = 37.8 µg/dL (SI: 1042.8 nmol/L)

Urinary free cortisol = 1925 µg/24 h (<4-50 µg/24 h) (SI: 5313 nmol/d [11-138 nmol/d])

Random ACTH = <5 pg/mL (10-60 pg/mL) (SI: <1.1 pmol/L [2.2-13.2 pmol/L])

Total testosterone = 182 ng/dL (8-60 ng/dL) (SI: 6.3 nmol/L [0.3-2.1 nmol/L])

DHEA-S = 1490 µg/dL (18-244 µg/dL) (SI: 40.38 µmol/L [0.49-6.61 µmol/L])

Which of the following is the most likely cause of this patient’s current presentation?

A. Surreptitious use of exogenous glucocorticoids

B. Adrenocortical adenoma

C. Adrenocortical carcinoma

D. Neuroendocrine tumor

E. Primary pigmented nodular adrenocortical disease

2 A 72-year-old woman is referred for management of osteoporosis, which was diagnosed at age 68 years when she had a DXA scan revealing T-scores of –3.2 in the right femoral neck and –2.9 in the left total hip. She took alendronate for 1 year and stopped due to the development of osteonecrosis of the jaw. She has not tried any other medications. She went through natural menopause at age 40 years and has not taken estrogen. She has no history of fragility fractures, kidney stones, or parathyroid disease.

Physical examination reveals a 2-cm area of exposed yellow bone in the right upper maxilla.

Laboratory test results:

Serum calcium = 8.6 mg/dL (8.2-10.2 mg/dL) (SI: 2.2 mmol/L [2.1-2.6 mmol/L])

Serum phosphate = 3.0 mg/dL (2.3-4.7 mg/dL) (SI: 1.0 mmol/L [0.7-1.5 mmol/L])

Serum creatinine = 0.9 mg/dL (0.6-1.1 mg/dL) (SI: 79.6 µmol/L [53.0-97.2 µmol/L])

Glomerular filtration rate (estimated) = 72 mL/min per 1.73 m² (>60 mL/min per 1.73 m²)

Serum intact PTH = 60 pg/mL (10-65 pg/mL) (SI: 60 ng/L [10-65 ng/L])

Serum 25-hydroxyvitamin D = 26 ng/mL (30-80 ng/mL [optimal]) (SI: 64.9 nmol/L [74.9-199.7 nmol/L])

Serum albumin = 3.5 g/dL (3.5-5.0 g/dL) (SI: 35 g/L [35-50 g/L])

Serum alkaline phosphatase = 110 U/L (50-120 U/L) (SI: 1.84 µkat/L [0.84-2.00 µkat/L])

A second DXA scan reveals declining bone mineral density in both hips, with T-scores of –3.5 in the right femoral neck and –3.2 in the left total hip.

Which of the following should be recommended in addition to adequate calcium and vitamin D supplementation?

A. Raloxifene

B. Zoledronic acid

C. Denosumab

D. Romosozumab

E. Teriparatide

3 An 83-year-old woman with a 25-year history of type 2 diabetes mellitus presents for follow-up. Her hemoglobin A_1c level was approximately 6.5% (48 mmol/mol) for many years. Over the past 12 months, it has risen to greater than 8.0% (>64 mmol/mol). The patient reports that her diet is poor. She eats cake and cookies, especially at bedtime, although this is not substantially different from what she has done for years. She reports being in her usual state of health except for fatigue, lightheadedness, occasional loose stool, and unsteadiness on her feet. Review of her medical record reveals a 20-lb (9.1-kg) weight loss over 3 years. Current medications for blood glucose control are sitagliptin and metformin.

On physical examination, she is a frail elderly woman who needs help with ambulation. Her blood pressure is 131/71 mm Hg, and pulse rate is 84 beats/min. Her height is 64 in (162.6 cm), and weight is 117.5 lb (53.4 kg) (BMI = 20 kg/m²). Examination findings are normal.

Laboratory test results:

Hemoglobin A_1c = 8.4% (4.0%-5.6%) (68 mmol/mol [20-38 mmol/mol])

Sodium = 132 mEq/L (136-142 mEq/L) (SI: 132 mmol/L [136-142 mmol/L])

Potassium = 4.2 mEq/L (3.5-5.0 mEq/L) (SI: 4.2 mmol/L [3.5-5.0 mmol/L])

Chloride = 96 mEq/L (96-106 mEq/L) (SI: 96 mmol/L [96-106 mmol/L])

Carbon dioxide = 26 mEq/L (22-28 mEq/L) (SI: 26 mmol/L [22-28 mmol/L])

Serum urea nitrogen = 16 mg/dL (8-23 mg/dL) (SI: 5.7 mmol/L [2.9-8.2 mmol/L])

Creatinine = 0.62 mg/dL (0.6-1.1 mg/dL) (SI: 54.8 µmol/L [53.0-97.2 µmol/L])

Glucose = 342 mg/dL (70-99 mg/dL) (SI: 19.0 mmol/L [3.9-5.5 mmol/L])

Which of the following is the best next step in this patient’s management?

A. Initiate insulin therapy

B. Measure fructosamine

C. Perform abdominal CT

D. Add glimepiride

E. Measure serum somatostatin

4 A 56-year-old woman is referred for cardiovascular risk management. She has a history of moderate hypercholesterolemia. Despite multiple attempts, she has been unable to take statins for many years because of muscle aches. She has no major concerns or other medical problems. Medications include ezetimibe, 10 mg daily, and aspirin, 81 mg daily. She does not smoke cigarettes or drink alcohol. Family history is notable for premature cardiovascular disease in her 49-year-old brother (nonsmoker) who underwent placement of 2 coronary stents. Her mother, who had a 40 pack-year history of cigarette smoking, had coronary bypass surgery at age 74 years.

On physical examination, she is an anxious-appearing woman in no acute distress. Her blood pressure is 132/84 mm Hg. Her height is 63 in (160 cm), and weight is 178 lb (80.9 kg) (BMI = 31.5 kg/m²). The rest of the examination findings are normal except for abdominal adiposity.

Laboratory test results (sample drawn while fasting):

Total cholesterol = 211 mg/dL (<200 mg/dL [optimal]) (SI: 5.46 mmol/L [<5.18 mmol/L])

Triglycerides = 130 mg/dL (<150 mg/dL [optimal]) (SI: 1.47 mmol/L [<1.70 mmol/L])

HDL cholesterol = 55 mg/dL (>60 mg/dL [optimal]) (SI: 1.42 mmol/L [>1.55 mmol/L])

LDL cholesterol = 130 mg/dL (<100 mg/dL [optimal]) (SI: 3.37 mmol/L [<2.59 mmol/L])

Non-HDL cholesterol = 156 mg/dL (<130 mg/dL [optimal]) (SI: 4.04 mmol/L [<3.37 mmol/L])

Lipoprotein (a) = 26 mg/dL (≤30 mg/dL) (SI: 0.93 µmol/L [≤1.07 µmol/L])

Hemoglobin A_1c = 5.2% (4.0%-5.6%) (33 mmol/mol [20-38 mmol/mol])

Creatinine = 0.84 mg/dL (0.6-1.1 mg/dL) (SI: 74.3 µmol/L [53.0-97.2 µmol/L])

TSH = 1.8 mIU/L (0.5-5.0 mIU/L)

She is unwilling to try statin therapy again. Using the American College of Cardiology/American Heart Association risk calculator, you calculate her 10-year cardiovascular risk to be 2.5%. However, based on her family history, you are concerned that this tool underestimates her risk.

Which of the following is the best next test in the evaluation of this patient’s cardiovascular disease risk stratification?

A. Apolipoprotein B measurement

B. Apolipoprotein A-1 measurement

C. Carotid intima media thickness

D. Coronary artery calcium scoring

E. Stress echocardiography

5 A 66-year-old man is referred for management of type 2 diabetes mellitus. He has had type 2 diabetes for 16 years, and his regimen was transitioned to multiple daily injections (U500 regular insulin) 4 years ago. The dosage of U500 has been titrated over the past few years, but despite 175 units of U500 regular insulin 3 times daily (total daily dose = 525 units), his blood glucose remains suboptimally controlled with a hemoglobin A_1c level of 9.7% (83 mmol/mol).

The patient’s BMI is 57 kg/m², and he reports that his lifestyle is sedentary. His comorbidities include coronary artery disease status post coronary artery bypass grafting 8 years ago, obstructive sleep apnea, hypertension, hyperlipidemia, and stage 4 chronic kidney disease with microalbuminuria. His diabetes is complicated by neuropathy, which is currently well controlled with gabapentin. His wife reports that w...

Table of contents

• Cover
• Copyright
• Contents
• Endocrine Self-Assessment Program 2021: Part I
• Endocrine Self-Assessment Program 2021: Part II
• Endocrine Self-Assessment Program 2021: Part III