(Test Bank) Endocrinology And Mental Health Med-Challenger Chapter Exam Complete Study Guide

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Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Diagnose adrenal insufficiency. Stem & Answers A 35-year-old man presents with fatigue, loss of libido, and lethargy for the last 3 years. He has no medical history. He takes a multivitamin but no other medications. He smokes 1 pack of cigarettes every week and drinks 1 glass of wine each night. He does not use drugs. He is the manager at a retail clothing store. His review of symptoms is notable for a 15 -pound weight loss since his last visit 3 years ago. Vital signs are: temperature 37.4 °C, heart rate 95 beats /minute, blood pressure 110/65 mm Hg, respiratory rate 14 breaths/minute, and oxygen saturation 99% on room air. Findings on his head, ears, eyes, nose, and throat examination, as well as examinations of his neck, heart, lungs, abdomen, and neurologic stat usare all normal. His skin appears tanned, even under his clothes. You order laboratory studies that show a normal complete blood count, sodium level of 130, potassium level of 5.1, chloride level of 110, bicarbonate level of 25, blood urea nitrogen level of 13, creatinine level of 0.8, and glucose level of 90. You suspect adrenal insufficiency. What is the next test to order to confirm this diagnosis? • random serum cortisol and adrenocorticotropic hormone (ACTH) levels • antiadrenal antibodies • low-dose corticotrophin stimulation test • 24-hour urine cortisol excretion • Plasma cortisol level after infusion of adrenocorticotropic hormone (ACTH) Remediation Stuvia.com - The Marketplace to Buy and Sell your Study Material Question 2 Edited: Oct 7, 2016 Report Question Stem & Answers In which of the following patients with adrenal insufficiency is therapy with fludrocortisones necessary? • 42-year-old man who underwent pituitary surgery for Cushing disease • 27-year-old man recently diagnosed with empty Sella syndrome • 31-year-old woman with Sheehan syndrome • Key Point: Increases in cortisol levels above 20 mcg/mL after ACTH stimulation excludes adrenal insufficiency. Explanation: An increase in cortisol levels of more than 20 mcg/dL following ACTH stimulation excludes adrenal insufficiency. The low - and high -dose ACTH stimulation tests have similar rates of sensitivity and specificity. Some advocate a morning cortisol level as an initial screening test for adrenal insufficiency in ambulatory patients. A morning cortisol level below 3 mcg/dL is specific for adrenal insufficiency, and a morning cortisol level higher than 20 mc g/dL excludes all but the earliest cases of adrenal insufficiency. Once the diagnosis of adrenal insufficiency is confirmed, an ACTH level should be drawn to localize the defect to the adrenal gland or the hypothalamic -pituitary axis. In primary adrenal insufficiency, ACTH levels are most often above normal and hyperkalemia is common. In secondary adrenal insufficiency, ACTH levels are low or inappropriately normal. References : Bleicken B, Hahner S, Ventz M, Quinkler M. Delayed diagnosis of adrenal insufficiency is common: a cross -sectional study in 216 patients. Am J Med Sci. 2010;339(6):525 -531. Nieman, LK. Adrenal cortex. In: Goldman L, Schafer AI. Goldman -Cecil Medicine . 25th ed., 2016:1514 -1521 Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Characterize the therapeutic difference between primary and secondary adrenal insufficiency. Key Point: Replacement with the mineralocorticoid fludrocortisones is only necessary for those with primary adrenal insufficiency such as autoimmune Addison disease. Explanation: Fludrocortisone therapy is reserved for patients who have primary adrenal failure, because both cortisol and aldosterone secretions are affected due to destruction of the entire adrenal cortex. Of the cases described, the 24 -year-old with autoimmune Addison disease is the only patient with primary adrenal insufficiency. The other patients listed have secondary adrenal failure. In these cases, the renin - aldosterone -angioten sin system continues to work normally, making replacement with fludrocortisones unnecessary. References : Smith SJ, MacGregor GA, Markandu ND, et al. Evidence that patients with Addison's disease are undertreated with fludrocortisone. Lancet . 2014;1(8367):11 -14. White PC. Adrenocortical insufficiency. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics . 20th ed., 2016:2703 -2714. 24-year -old woman with type 1 diabetes mellitus diagnosed with autoimmune Addison disease Remediation Question 3 Edited: Oct 7, 2016 Report Question Stem & Answers A 45-year-old man presents to you because of a reduced libido and impotence. He states that he began noticing issues with his libido about 1 year ago but he is more concerned now because he has been noticing that his chest appears to be developing a breast -like appearance (more tissue, darker and larger nipples) and the tadalafil he is taking for erectile dysfunction does not seem to be helping as well as it did before. He denies any other health issues. On examination, his vital signs are normal and you confirm the presence of gynecomastia. The testes are small and insensitive. No abdominal masses are palpable. Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Describe the workup and treatment for a large adrenal mass. Key Point: Adrenal masses with suspicious imaging phenotype or size larger than 6 cm should be resected. Explanation: The patient described has a large (> 6 cm) adrenal mass, which is suspicious for adrenocortical cancer; thus, the patient should undergo resection of the mass. Any incidental mass of the adrenals greater than 6 cm in size or any mass evidenced on workup for a suspected adrenal disorder that is of this size, requires surgical resection. Radiologic characteristics suggestive of malign ancy include: • Irregular margins • Lack of homogeneity • Soft-tissue calcifications visible on CT • Hyperintensity compared with liver on T2-weighted magnetic resonance imaging You send the patient for diagnostic testing and discover levels of estrogen of 178 pg/dL (normal range, 13 -54 pg/dL), luteinizing hormone of 0.2, follicular -stimulating hormone of 0.3, and testosterone of 67 pg/dL (normal range, 250-800 pg/dL). Computed tomography (CT) shows a 7.3 -cm, irregular mass on the right adrenal gland. Which of the following do you recommend to this patient? • repeat CT in 6 months to monitor mass size • positron emission tomography • fine-needle biopsy of the adrenal mass • surgical resection of the mass Remediation Stuvia.com - The Marketplace to Buy and Sell your Study Material Question 4 Edited: Oct 7, 2016 Report Question Stem & Answers A 35-year-old man presents with fatigue and lethargy that he says have lasted for 6 months. He has no medical history. He takes a multivitamin but no other medications. He smokes 1 pack of cigarettes every week and drinks 1 glass of wine each night. He does not use drugs. He is the manager at a retail clothing store. His review of symptoms is a notable 15 -pound weight loss during the last 6 months. Vital signs are: temperature 37.4 °C, heart rate 95 beats/minute, blood pressure 110/65 mm hg, respiratory rate 14 breaths/minute, and oxygen saturation 99% on room air. Findings on his head, ears, eye s, nose, and throat examination are normal, as are the results from examinations of his neck, heart, lung, abdomen, and neurologic status. His skin is notable for a tanned appearance. You order laboratory studies that reveal a normal complete blood count, and levels of sodium of 130, potassium of 5.1, chloride of 110, bicarbonate of 25, blood urea nitrogen of 13, creatinine of 0.8, and glucose of 90. His baseline cortisol level is 3 mcg/dL, which is low. About 30 and 60 minutes after the injection of corticotrophin 250 mcg (an adrenocorticotropic hormone [ACTH]), his cortisol level is 4 mcg/dL. What is the most likely diagnosis? • tuberculosis Adrenal nodules with low CT attenuation values (< 10 Hounsfield units) and findings on rapid contrast washout (washout more than 50% after 10 minutes) are likely to be benign. Though they are rare, estrogen -producing adrenal tumors can occur and can present as described in this case. References : Bovio S, Cat aldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest . 2012;29(4):298 -302. White PC. Adrenocortical tumors. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics . 20th ed., 2016; 579: 2726 -2727. Stuvia.com - The Marketplace to Buy and Sell your Study Material • sarcoidosis • Addison disease • Sheehan syndrome • AIDS Remediation Educational Objective: Diagnose adrenal insufficiency. Key Point: A poor response to ACTH stimulation (increase < 18 mcg/dL) indicates adrenal insufficiency. A plasma ACTH level would further distinguish primary from secondary causes. Explanation: Chronic adrenal insufficiency is characterized by nonspecific symptoms such as fatigue, weight loss, and low energy. Because symptoms are often nonspecific, the diagnosis can be elusive. Because of mineralocorticoid deficiency, serum chemistri es will often show hyponatremia and hyperkalemia. Skin pigmentation is often dark. The diagnosis can be made with an ACTH stimulation test. A cortisol level is checked 30 to 60 minutes after administration of ACTH. The cortisol level after ACTH should rise to at least 18 mcg/dL. To distinguish between primary and secondary adrenal insufficiency, plasma ACTH levels must be obtained. In cases of primary adrenal insufficiency, the ACTH levels are high, but the adrenal gland is not properly functioning. In cases of secondary adrenal insufficiency, the pituitary is not producing ACTH, and the levels are low or low-normal. Sarcoidosis and tuberculosis can present with similar symptoms,; however, the laboratory values and imaging results would be different. AIDS can affect the adrenal gland as a chronic disease, but also through infection and malignancies. Treatment for HIV infection has greatly reduced this complication. Reference : Wiebke A. Disorders of the adrenal cortex. In: Longo D, et al, eds. Harrisons Principles of Internal Medicine . 18th ed., 2012. Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Recognize and list the causes and treatment of an adrenal crisis. Question 5 Edited: Oct 5, 2016 Report Question Stem & Answers A 32-year-old woman with a history of severe asthma presents to you with swelling, redness, fever, and heat in her left leg. You diagnose her with cellulitis and admit her for antibiotic therapy. The patient has had several asthma attacks this year treated with oral corticosteroids, but currently she is asymptomatic and her usual treatment is continued while in the hospital. After being in the hospit al for 12 hours, the patient's fever worsens and she starts experiencing nausea and vomiting. She is also complaining of severe right upper -quadrant abdominal pain. On examination, her abdomen is rigid but it is difficult to elicit pain on any particular quadrant of the abdomen, and bowel sounds are present. Her pulse is 110 beats/minute, blood pressure 95/62 mm Hg, and temperature is 101.2 °F. She tries to sit up but then complains of severe lightheadedness. Which of the following is the most i mportant next step in the treatment of this patient? • Order STAT chemistries and arterial blood gas values. • Increase the rate of the fluids the patient is receiving to 150 cc/hour. • Administer STAT intravenous hydrocortisone 50 mg followed by 50 mg every 8 hours. • Administer STAT morphine for the pain and consult a surgeon for a possible acute abdomen. Remediation Stuvia.com - The Marketplace to Buy and Sell your Study Material Question 6 Edited: Oct 4, 2016 Report Question Stem & Answers A 58-year-old man presents to you as a new patient. He has not seen a physician in several years. The patient states that he is getting up at night frequently to urinate, he is thirsty most of the time, and he has blurry vision. He has also been bruising easily and has noticed "stretch marks" in his abdomen. He also says he has noticed that he looks more tanned. On physical examination, his pulse is 8 2 beats/minute and his blood pressure is 166/92 mm Hg. The abdomen is large with purple striae and his extremities are thin with several ecchymoses. You ask the patient to squat and stand up, but he is unable to stand up without assistance. The patient's skin shows darker pigmentation in his skin-fold areas. Key Point: Patients taking long -term steroids are at risk for secondary adrenal insufficiency. They may become underdosed during times of infection or major illness, resulting in an acute adrenal crisis. Treatment involves intravenous hydrocortisone. Explanation: This 32 -year-old woman has a history of asthma and presented with cellulitis. Because steroids are commonly used with patients with asthma, these patients are at a higher risk of having iatrogenic adrenal suppression and they a re at higher risk for adrenal crisis when acutely ill. In this scenario, the patient's overall condition is worsening and she has presented with findings suggestive of adrenal crisis (worsening fever, nausea, vomiting, and abdominal pain mimicking acute ab domen). Under these circumstances, she should receive immediate treatment with STAT intravenous hydrocortisone 50 mg followed by 50 mg every 8 hours. Chemistries, arterial blood gas levels, and an increase in intravenous fluids are also appropriate, but th ey would not be the first step. If confirmation of adrenal insufficiency is being considered, then dexamethasone can be administered instead of hydrocortisone to prevent altering results for cortisol levels. Dexamethasone can be administered immediately and blood drawn once therapy is initiated. References : Michels A, Michels N. Addison disease: early detection and treatment principles. Am Fam Physician . 2014;89(7):563 -568. Nieman LK. Clinical manifestations of adrenal insufficiency in adults. Revised March 8, 2017. Accessed July 28, 2017. Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Identify the appropriate treatment for Cushing disease. Key Point: Cushing disease is a pituitary cause of ACTH -dependent Cushing syndrome. Treatment is trans -sphenoidal microsurgery. Explanation: This patient presents with classic symptoms of Cushing disease, including striae and easy bruising. The diagnosis requires 2 d ifferent first -line test results to be abnormal: late -night salivary cortisol (2 measurements), 24 -hour urinary free cortisol excretion (2 measurements), or an overnight 1 mg dexamethasone suppression test. Plasma ACTH levels can be used to determine if th e hypercortisolism is ACTH dependent or not. If plasma ACTH is low (< 5 pg/mL), then the disease is ACTH -independent, and computed tomography should be done to look for adrenal mass. If it is high (> 20 pg/mL), then the disease is ATCH -dependent, and eithe r MRI or further laboratory testing must be done to differentiate between a pituitary adenoma or ectopic ACTH secretion as the cause. For patients with identified pituitary adenomas, surgical resection by trans -sphenoidal microsurgery is the treatment of choice, because it leads to cure in more 95% of cases. Ketoconazole and adrenalectomy are reserved for patients with adrenal tumors that lead to His 24 -hour urinary free cortisol excretion rate is 4 times the upper limit of normal, and his cortisol level is elevated after a dexamethasone suppression test. A random plasma adrenocorticotropic hormone (ACTH) concentration is high (> 20 pg/mL). Magnetic resonance imaging (MRI) shows an 8 -mm-sized pituitary adenoma. His laboratory studies and radiologic diagnostics confirm a diagnosis of Cushing disease. Which of the following is recommended for this patient? • trans -sphenoidal microsurgery • ketoconazole • radiosurgery • adrenalectomy Remediation Stuvia.com - The Marketplace to Buy and Sell your Study Material Question 7 Edited: Oct 3, 2016 Report Question Stem & Answers A 47-year-old woman with Cushing syndrome needs further work -up. The results of her dexamethasone suppression test were reported as 350 mg (normal range, < 50 mg). Her 24 -hour urine free cortisol test is also elevated. You order an adrenocorticotropic hormone (ACTH) level, the result of which is 102 ng/L (normal range, 9-52 ng/L). Which of the following is considered the go ld standard to differentiate a pituitary vs an ectopic source of ACTH? • inferior jugular venous sampling (JVS) with corticotropin -releasing hormone (CRH) stimulation • metyrapone -suppression test • high-dose dexamethasone suppression test • inferior petrosal sinus sampling (IPSS) with corticotropin -releasing hormone (CRH) Remediation Cushing syndrome (the latter is the treatment of choice). Radiosurgery can be used for pituitary adenomas but is generally reserved for patients who have failed surgical therapy. References : Fathalla H, Cusimano MD, Alsharif OM, Jing R. Endoscopic transphenoidal surgery for acromegaly improves quality of life. Can J Neurol Sci . 2014;41(6):735 -741. Nieman LK. Establishing the cause of Cushing’s syndrome. Revised November 26, 2013. Accessed July 28, 2017. Nieman LK. Establishing the diagnosis of Cushing’s syndrome. Revised June 19, 2015. Accessed July 28, 2017. Stuvia.com - The Marketplace to Buy and Sell your Study Material Question 8 Edited: Oct 7, 2016 Report Question Stem & Answers In a patient with an established diagnosis of Cushing syndrome, an adrenocorticotropic hormone (ACTH) level is drawn and found to be undetectable. Which of the following is the next step in this patient's work -up? • exploratory surgery of the adrenal glands • metyrapone -suppression test • Educational Objective: Determine the cause of ACTH -dependent Cushing syndrome. Key Point: ACTH -dependent Cushing syndrome can either be due to a pituitary adenoma or ectopic ACTH secretion. The gold standard to differentiate between those causes is CRH stimulation combined with IPSS. Explanation: IPSS with CRH stimulation is the single test that has been described as the gold sta ndard to differentiate between an ectopic and pituitary source of ACTH. Because the technique for IPSS is so difficult, inferior JVS with CRH is an acceptable diagnostic test; however, it fails to yield an appropriate diagnosis in approximately 10% of case s. It can be performed first; however, if a diagnosis is not made, then IPSS is required. Neither a high -dose dexamethasone test nor a metyrapone -suppression test will adequately distinguish between ectopic or pituitary sources of ACTH. References : Guo YW, Hwu CM, Won JG, Chu CH, Lin LY. A case of adrenal Cushing's syndrome with bilateral adrenal masses. Endocrinol Diabetes Metab Case Rep. 2016;2016:150118. Nieman LK. Establishing the cause of Cushing’s syndrome. Revised November 26, 2013. Accessed July 28, 2017. Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Examine the role of adrenocorticotropic hormone (ACTH) in determining the cause of Cushing disease. Key Point: Low ACTH levels in patients with Cushing syndrome indicate an adrenal cause. CT of the adrenal glands looking for an adrenal mass is the next step. Explanation: In the diagnostic paradigm for Cushing syndrome, establishing whether the syndrome is ACTH -dependent or ACTH -independent dictates the next step in the work -up. This patient has established ACTH -independent Cushing syndrome. Because the vast majority of these cases are due to solitary adrenal adenomas, the next step is CT of the adrenal glands. Exploratory surgery of the adrenal is not recommended because other noninvasive means exist to establish the diagnosis. PET is reserved for patients with adrenal carcinoma to detect metastatic disease. A metyrapone -suppression test is not indicated in this setting. References : Aktas GE, Soyluoglu Demir S, Sarikaya A. Bilateral symmetrical adrenal hyper metabolism on FDG PET/CT due to Cushing syndrome in well differentiated neuroendocrine carcinoma. Rev Esp Med Nucl Imagen Mol. 2016;35(2):118 -120. Nieman, LK. Adrenal cortex. In: Goldman L, Schafer AI. Goldma n-Cecil Medicine . 25th ed., 2016:1514 -1521 computed tomography (CT) of the adrenal glands • positron emission tomography (PET) Remediation Question 9 Edited: Mar 28, 2018 Report Question Stem & Answers A 52-year-old man presents to you because he has been having episodes of headache, palpitations, and sweating for the past 6 months. He has attributed them to panic attacks. He recently checked his blood pressure at a local store and found that it was elevated, and that is the reason for today's visit. He also discloses that his grandfather had neurofibromatosis. Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Diagnose pheochromocytoma. Key Point: Pheochromocytoma can be diagnosed using 24 -hour urine collection of metanephrines or plasma -free metanephrine levels. Plasma -free metanephrine testing is highly sensitive, and it should be used for patients with a high index of suspicion for pheochromocyto ma. Explanation: Plasma -free metanephrine testing is recommended to diagnose pheochromocytoma when the pretest probability is high. This patient is experiencing the classic triad of symptoms, with hypertension and tachycardia, and has a family history of neurofibromatosis, which suggests a possible genetic cause and a high likelihood of pheochromocytoma. During an attack, plasma -free metanephrine testing is highly sensitive (> 97%) and specific (> 85%). However, the test is recommended to be don e with the patient supine for 30 minutes with an indwelling intravenous catheter, which can be difficult in outpatient settings. Additionally, the test has a high false -positive rate (approximately 15%). A 24-hour urine collection for metanephrines (97% se nsitive, 89% specific) will also show increased metanephrines; the accuracy of the 24 -hour urinary levels for metanephrines can be improved by indexing urinary metanephrine levels by urine creatinine levels. This 24-hour As you s tart examining the patient, he has what he calls a "panic episode," and you notice that his blood pressure is 170/100 mm Hg, his pulse is 124 beats/minute, and he has profuse diaphoresis. This episode lasts for 10 minutes and then his blood pressure drops to 142/84 mm Hg and his pulse decreases to 88 beats/minute. You have a high index of suspicion that this patient may have pheochromocytoma. If done properly, which of the following is most likely to yield this diagnosis? • 24-hour urine collection for metanephrines • clonidine -suppression test • magnetic resonance imaging (MRI) of the adrenal glands • plasma -free metanephrine levels Remediation Stuvia.com - The Marketplace to Buy and Sell your Study Material Question 10 Edited: Jan 29, 2018 Report Question Stem & Answers Which of the following is NOT part of an appropriate preoperative regimen for a patient undergoingresection of a an adrenal pheochromocytoma? • Liberalize salt intake (high -sodium diet) at least 10 days prior to surgery. • Metoclopramide for nausea control. • Start an alpha -/beta -adrenergic blockade. • Discontinue allergy medication. urinary metanephrine test is often used as first -line screening for patients, because there is a lower index of suspicion for the disease in most cases, the test is easier to administer, and it has a lower false -positive rate. The clonidine -suppression test is useful for distinguishing between high levels of plasma norepinephrine caused by release from sympathetic nerves and those caused by release from pheochromocytoma. A decrease of less than 50% in plasma norepinephrine levels after clonidine administration is normal, whereas persistent elevations are indicative of pheochromocytoma. References : Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002 Mar 20;287(11):1427 -1434. Garg H, Uppal M, Sreedharan SK, Aggarwal S. Laparoscopic management of recurrent pheochromocytoma: a case report. J Minim Access Surg . 2016;12(3):278 -280. Young WF Jr. Clinical presentation and diagnosis of pheochromocytoma. Revised September 20, 2016. Accessed July 28. 2017. Yu R. Pheochromocytoma. In: First Consult . 2012. Accessed April 5, 2017. Stuvia.com - The Marketplace to Buy and Sell your Study Material Educational Objective: Appropriately test for pseudo -Cushing syndrome. Key Point: Pseudo -Cushing syndrome, or physiologic hypercortisolism, can occur in patients with poorly controlled diabetes and, rarely, alcohol use disorder. A CRH test after administering low- Stem & Answers A 56-year-old woman with alcoholic liver disease presents to you with the complaint of being tired but states that she is otherwise healthy. She currently drinks 3 six -packs of beer every day and tells you she is not interested in alcohol cessation. On examination, her height is 5 feet 6 inches, she weighs 186 pounds, and her blood pressure is 147/84 mm Hg. She has a buffalo hump and striae in the abdomen that are pink in color. She is able to stand up after squatting. You test her nonfasting, glucose level, which is 189 mg/dL. On initial work -up, you order a morning cortisol level, which is 16 mg/dL, and an A1c level, which is 7.3%. You confirm a diagnosis of diabetes, but you are concerned the patient may have Cushing syndrome given her elevated cortisol level. You order a dexamethasone -suppression test (1 mg), the result of which is 14 mg/dL. Which of the following will best rule out the diagnosis of Cushing syndrome for this patient? • low-dose dexamethasone followed by corticotropin -releasing hormone (CRH) stimulation • adrenocorticotropic hormone (ACTH) levels • high-dose dexamethasone test • 24-hour urinary cortisol excretion Remediation