oss jieema ore || vfs Ses) (silaiim) ‘A patient with long-standing renal fellure secondary to focal segmental glomerulosclerosis undergoes parethyroid biopey that shows marked hypomplacis. On physical examination, taging over tho chook aliits facial muscle spasm, Which ofthe fellowing sets of laboratory valuas most likely be seen inthis oationt? hemor ce shorphate | phosphate 13 14 16 16 i 18 Block End ExplanationFle J bone Edt Yew Favorites 13 14 16 16 Bt i Block End Taok Hep woes NOON [LVI lone The cornect answer is C. The patient is surfering fom hyperparathytoidism secondary toreral dis2ase, alco known as renal osteodystrophy. Conversion of vitarnin D ta its active fermis impaired in paiiorts with renal dicoase. As arecull, calcium absorption trom the gut is decreased, which than leedsto an increase in lovele af parathyrod hormone (PTH). Furthermore, tha Increase in phosnhate levels due tn the patient's renal disease leeds to a dectease in calciurn levels. The patients labs, therefore, rellect an increased PTH, a dacreasec serum calcium level, and increased phosahate, The increase in PTH aclivates osteoclasts, leading to bone resoration and Increased levels af alksline phosphatase. As not correct. Patients with renal disease have decreased serum calcium levels secondary ia Impaired acivalion ofvitarin D tv 1,26(0H)203. Leck of blulogically active vlarrin D results in detreased absorplion of calciurn fron ihe gastrointestinal treet Bie not comrect. This oat of lab values is characterielc of a patient with primary hypeinarathyroidicre. The primary cifference between the I2b results for a patient with primary versus secondary hyperoarathyroidism is the relationship between parathyroid hormone (PTH) and serum calcium, Patients with primary hyperparathyroidism will have a resultant increase in serum calcium levels, while those wih secondary hyperparathyroidismr havea decreased serum cal:ium level, which tren leads to the Increase in PTH. 1s not correct. increased levels cr parathyrald hormone in patients wth secondary hyperparathyroidism leads to osteoclast activabon, Increased bone resorption, end an increase in alkaline ahosphatase. Eis not cotrect. Patents with renal disease have increased, not decroased, levels of phosahate ime SF @ mene Pied aeFle Edt Yew Favorites 13 14 16 16 i 18 Block End USMLERx :: Your prescription to USMLE Success - Microsoft Internet Explorer Taok Hep 7 jem2 ori |] [ vfs Ses) [si{r]im| ‘A 86-year-old man with history of chronic cough, dyspnea, anc a S0-packeyear of cigarette smoking comes to the - clinic aftor noticing come blood in his sputum. He roparis thathe fools lothargic and has loct 18 ky (40 Ib) over tho past 3 months with no changas in cietor exercise, Laboratory studies show a serum Nat level of 120 mEd/dL. While awaitng a CT sean, the petient suffers a seizure ands rushed tothe emergency department af the nearest haspital Which of the following is most lice to be elevates in this patient? A.ACTH B.ADH ©.Perathyroid hormone D.Renin E.Tumor necrosis factor-a ExplanationFle Edt Yew Favorites Tools 13 14 16 16 a tt i Block End remz ris | |v [fH Se) The cortect answer is B. This vigretis is mas consistent with a syndrome of Inaprropriste secretion of ADH due toa lung nenplasm ADHis secreted ay he posterior pituitary and stimulates the expression of aquaporins in the renal collecting ducts, resulting in transport of water inta the renal medulla from the ductallumen anc hence water retention in the kidneys. When lavels af this hormane ate nappropriataly elevated, excessive water retention results in hyponatremia, which can lead to seizures, ADH can be produced ectopicalyy in the seting of malignancy, classically by smal cell uno cancer. == Ais not comect. ACTH can be produced eciopically in the seting ofmalignancy, especially small sell lung cancer. However, excessive levels of ATH would resultin, Custing’s syndroma, and tha vignotte provides no symptoms or signe that would ko consistent with this cordition Cis not comect. ®aratiyrcid hormone (PTH) can be preduced ectopicallyin the setting of malignancy andis associated with a variety ofneopiasia, including scuannous cell lung cancer, oreasi cancer, and rrultple myelama. However, excessive lavels of PTH woUld result in typercalcemia, and the vignette does nat provide any indication (circumoral paresthesias, Chvastek’s and Trousseau’s signs) that would be mostconsistent with this condition, Nete that these symptoms can also ‘occur Inthe selting of malignancy due to production of PTH+related peptide by turn cells. Dis not correct. Hyperraninernia ¢ae0 not ically cour oe narancoplactic syndione anc would ganeraly cause hyperaldosteranism, resuting in hypematramia and Fynakelemia While seizures can he a consequence of severe hynernaterria, the vignette does not mention any siars or symatams af hypokalemia (nausea, vorniting, mustle weakness, caidisc cysthytimias) Eis not correct. Tumor nacrosis factor-o can be produced ectopically inthe setino of ‘malignancy and parallels parathyroid hormone bath in causing secondary hypetcalcemis and in the cancers with which excesswe orodusticn is associated. eee oi Zhe Ul @ mene a) ay)Roo eet te eee Re tiger eg nO Macreee en ete Fle Edt Yew Favorites Tool Hep ait a2 remo ort [<)> ville) (sium) ‘A 33-year-old woman preserts to the emergency department after faintng, She complains of abdominal pain and generalized wealnoss, and ralaioc a hiclary significant far woight loce, amenorthea, and inienge cravings for french ties. Physical examination reveals hyrerpigmentation ofthe mucous membranes, elbave, and knuckles. Laboratory studies are significant fr a serum cortisol lavel af 10 gid. following ACTH stimulation (normal > 20 joi following ACTH stimulation). Which of the following is mostlikely to ke elevated in this patient? A.ACTH B.Alcosterone ©.Protactin D. Testosterone E.Thitoid-stimulating hormone 13 : 16 z 16 tt 18 Block EndFle Edt Yew Favorites Tool Hep Seas [roms rte [ |v [fH Se) [sili] Lexpranrawory The correct answer is A, This \onets de hypotension and salt-ctaving, as indicated in this case by the history of fainting anc z craving far french ties, 13 14 C is not cotrect. While an elevated level of prolacin may cause amencrthea this i hormone is not aftecteu by the typothalarnic-ptuilary-actenal axl. 16 Dis not correct. Adrenal incuficiency causes 8 deftciencyin androgen production, i it Which recute in decroaced corum levels of toctoctatone. Clinically, itie distinguished bi bythe aasence cf pubic and aviary hair, decreased libida in men, ane amenorrhea inwoman Block End Eis not comect. The secretion of thyroid-stimulating hamone (TSH) is net affected by the Fypothalamic-ptuitary-acrenal axis, Therefore, TSHis unlkely toe elevated in the setting of decrease comisol or increased ACTH, ‘Addison's 1° deficiency of aldosterone and cortisol due to adrenal akophy, casing hypotension disease thyponatremic volume contraction} and skin hyperpigmentaton (de to MSH, «by product of P ACTH production from FOMC). Characterized by Adrenal Airophy and Absence of humane prnkiction; inves All 3 eetieal isd Susu dl cone @ mene oe Ss Caled O80) awRee eee eee Negroes Fle Edt Yew Favorites Tool Hep ait ata [ems ore |<) (siieii=) ‘A 60-year-old woman with a 55-pack-year history of smoking presents io the emergency depaitmentwith nausea and vomiting, heacacho, malaise, ard diffuse acnas. A CT ocan chavs 3 colitary nodule inthe right uppor lobe af the lung, Laboratory studies are signifeant for a serum Ca2+ level of 14.2 mgldL, 2 serum phospnata level af .6 mgidL, anda Serum alkaline phosphatase activiy af 8! LIL. The factors that acccunt for this patient's laboratory findings act primarily at which ofthe folowing locations? A.Adrenal cortex and intestines B. Adrenal cortex and renal tubules C.Intestines and bones D.Renal tubules and bones E.Renal tubules and pancreas 13 : 16 z 16 tt 18 Block EndFle 2] bone Edit vew Favorites 13 14 16 16 i 17 i Block End Taok Hep = ema ors |) [>| v Ie lal ese) (Eexitanation] The c itsurfering from alkaine palase aviv. This is consistent wih Mperea ceria due a he acon or Betahyroidhormane-elaed peice CTH), whieh produces pnyiologk: eects ha ro92 of paathyois harmon (PTH): increase kona reaerpton ard iereasee ronalabsomtin af 632s, ultng in elvated lovee ofthecealectoiyos in he Ais not correct. ®arathyrcid hormone (PTH) and PT+-related peptide do not act at the adrenal cortex orthe intestines The adrenal cortex is. the primary site of action for ACTH and ACTH-Ike peptide, f ction for 1,25- dihydrexycholecalcttera Bis not comrect. Parathyroid hormone (PTH) and PT+-related peptide have no action atte acrenal coftex ACTH snd ACTH-like peplide (katt ofwich cen be elaborated by neoplastic cell, resulting in Cushing's syerome} act primarily a the edrenal cortex C ie not comrect. The intestines and hanes are primary sites of action for | iihydrmychalecaleifero! (rtarin D) While parathyroid (PTH) and PTH-ralated peptide stimulate pracucton of 1,28-dihydronsholecalciferol, producing secondary effects at the irtestinas, these hormonas do notact primarily on the intestines Eis not correct. Parattyrcid norncne (FTH) and PT+-releasing peptice act orimavily atthe renal tubules and hones to increase serum Ca2+ levels. These noinanes do ctirfluence the pancreas, although pancreatic tumors have been shown ta cccasionaly sectete PTH eee oi Zhe) @ mene a) ay)eno eet te eee i egnr pie ie Fle Edt Yew Favorites Tool Hep ait ans [remo orte [<)> vise) [siieii=) ‘A 60-year-old waman with a Fistery of chranie renal insufficiency presents with prurius, diffuse bane pain, and proximal muscle woakrass. Laboratory studioc chow a sorurn Ca2+ lovol of 8.6 maidL, a serum phasphate level of 6.0 mgjeL, a sarum creatinine loval of 4.6 mg/dL, and an intact parathyroid hormone level of 300 pyirnL. The lahoratay findings in this patiant are rmact likely due to which of the following conditans? A Parathyroid adenoma B Parathyroid insuficiency ©. Renal failure D. Underlying malignancy E.Vitarrin D intovication Explanation Block EndFle J bone Edt Yew Favorites 13 14 16 16 Bt i Block End Taok Hep a ems ors |<) [>| v Ie lal ese) ([Exptanation ] The correct answer is C. This vignette describes a patientwit seconcary hypetparatnytoldism due 19 chronic renal insumclency ar renal astecdystrapry. The central problems in this disode are impaited Oa2* reabsurplion and phosphate excretion ftom the kidneys due to nephron loss. The resulting hypocalcemia stimulates inereesed secretion of parathyroid hormone (secondary hypetparathyroidierr), causing increased bane tumaver and contributing to the hynetnhosphetemia Mareaver, nephran lass results in impalred conversion of 25-04 vitamin D to 1,26-dityciows vitamin D, reducing Ca2+ absnmption from the intestines and thus evacerbating hypocalcemia in this syndrome, ‘Ais not correct. Parathyroid adencma would cause incteased secretion of paratiytoid hormane, resulting in hypercalcemia end hypophosphatamia rather than hypocalcemia and hyperphosphatemia, Bis not comect. Paratiyrold Insurfelency would result in typocaicemia but cannot accountforthe hyperphosphatemta presented in this case. Dis not corroet. Malignancy usually results in hyporcaleamia vithor duo to tybe matastases to hone (with increased sarum alkaline phosphatase activly and hypeinhosnhtemia) or due ta procucion of parathyroid hormone-related peptide ‘ith hyraphosphiaternia) Eis not correct. Vitzmin D intoxication resuts in tynercaleernia and hyperphosphetemia and thus would be inconsistent with the low calcium value presented in the vignette. However, vitamin D intoxication mayindeed present with the Clinical tnaings stated above, Including prurtis, bane pain, weakness, and renal uystuneton, ime SF @ mene Pied aeeno eet te eee i egnr Fle Edt Yew Favorites Tool Hep ote ems ort [<)> veils) (sium) ‘A 47-year-old men with a history ofhyperoarathyroidism presents tothe piysician with athyroid mass. Laboratory studios chow olovatod sour calcttonin jovols. Tho pationtroports that rnultiple family mamaors hava had similar health problems. Which of the fallowing is the mest ikely pathology ofthis patient's thyroid mass? A.Atrophic folicles with lvmphooyte infitrate and cerminal centers Nests of enzyine-secreting tumor ealls in an amyloid-fllad stroma C. Papillary pattern witn ground-glass nuclel and psammoma bodies D. Sheets of undifferentiated, pleomorphic cells, Uniform folicles with snarse cnlloid and a large cell ining 13 Explanation 14 16 16 tt 18 Block EndFle 2] bone Edt Yew Favorites 13 14 16 16 Bt i Block End Naseem Charterer nee Meare eee aie te eet Taok Hep sus [rome orte [ vised (sium) ‘A 54-year-old man with a history of smoking and lung cencer develops hypercalcemia. He is enrolled ina research studyto accocs the offcacy of a now synihaiic agontto tost this cordition Afor sovaral days oftreatmont, ho roports Persistent numbness and tingling around his mouth. Physical exarrination is significantfor positive Chuostaks and Trousseau's signs. An axcess cf which ofthe fallewing mast likely accaurts for ‘his patients new symptams. and sions? A Calcitonin Parathyroid hormone ©.Perathyroid horrone-telated peptide D. Thyroxine E.Vitarrin D 13 : 16 z 16 tt 18 Block EndFle Edt Yew Favorites Tool Hep 13 14 16 16 a tt i Block End — rome or 38 [> [viele | Explanation The correct answer is A. This vignette describes a patiantwith classic symptoms and signs of hypocalcemia. ail ofthese findings can be attrbutedto the prysialogic effects of calcitonin. Calcitonin is normally secieted in resronse to elevated levels af Serum Caz+ and causes decreesed tone resorplion of 22+, resulting in lower Seruin Caz levels, Bis not correct. Parathyroid hormone (PTH) asts to increase serum Ca2e and phosahate levels by'increasing bane resarption and renal reabsorption of C224 Acditianally, PTH-related peptide stimulates canversian of inactive 25-0H vitamin 0 to active 1,25-OH wiarrin , resulting in hyp2rcalcerria rather than hypocalcemia Cis not comrect. Parathyroid harmone-related aeptice (PTHrP) acts like parathyroid hormone (PTH) to increase serum Ca2+ and phosphate levels ky increasing bone resorption and renal reahsomption af Ca2+. Adultionclly, PTHP stimulates conversion ofinactive 25-H vitarnin D to active 1,26-0H vitamin D, resulting in nypercalcernia raine than hypocalcemia, Metastatic érnall cell ung cancer can plausioly account ior j nodule palpable in the neck and is generally associated with paraneoplasic hypetcalcemia secondaryto elaboration of FTHIP. Dis not comroct. Thytovine is goncrally nat known to significantly aft corum Ca2+ lexels, Tstefore, excess thyroxine would net ba expected ta eatisa hypacalcarna The functions of hyrxine are summarized by tne “4 B's" Brain maturaion, Bone ova, @-adienerac effects, and increeseBasal matagolic rate Eis not correct, Vitamin D stimulates Ca2+ and phosphate absorgtion fram the intesiines and increases bore resorption, resulting in increased serum Ca2> and pphosahate levels, Hence, excess vitamin D would resultin hypercalcemia ratner than hypocalcemia, with nanspecite sympoms of rypercalcemia sucn as malaise, fallgue, depression, and dituse aches and gains. Hypercalcernia and hypophespnatemia are evident an laboratory evaluaton, eee oi Zhe Ul @ mene a) ay)eno eet te eee i egnr pie ie Fle Edt Yew Favorites Tool Hep ot es remo ort [<)> vile) [sieii=) ‘A 54-year-old man with a history of coronary artery disease and high cholesterol presents tothe physician with increasing lower oxtromity aderna. Hic blood procsure is 190/110 mmHg, and laboratory studios show hypematremia and Fypokslemia Imaging shaws no abnormalities exceptan area of right renal artery vescal eanstricton, Which of the following are the Ikely aldosterone and renin levels inthis rationt? A Decreasedidetreased B Decreasedielevated ©. Elevatedidecreased D. Elevatecielevated E.No changeina change Explanation Block EndFle Edt Yew Favorites Tool Hep Oe Sea ee (Sonim) The correct answer is D. The patienthas renal atery sienasis leacing to secondary hypetalcosteranism The constictian in he tgnt renal artery is causing hypopemusion fle rightkicney leaving to an increase in renin production, The increased renin duction is causing an increase in eldoste Ais not conect. Decreased levals ofaldosiernne and renin wnuld be an unikely combinstion in a patent unless both renin-anciotensin system dysfunction and : acrenal dysfunction are present 13 Bis not comect. 4 decreased aldosterone and an increased renin lavel is seen in 14 patients with primary adrenal hypotunetion, such as occurs in patients with Addison's i disesse The fenin-angiotensin system licks into averdive in these patients asa _ response to the low aldosterone levels, i 17 Cis not correct. An incteased aldosterone level paited with a decreased renin level Hee ‘would be seen in a paiert with primary hyperaidosteronism, such ss in a patient with an aldosterone-secrating adanama or adrenal hyoemlacis, Theee pationis have a Block End | | decreasad level af renin due ta the negatwe feedback effect ofincresed aldesterane levels on the renin-angiotensin system Eis not correct. Changes in aldosterone and renin levels would he expected in this patient ase Hyperaldosteronism Primary (Conn's al cc turner, resulting Treatment includes syndrome) in hypertension, hypokalenia, metabolic spironolactonie, aK dl cone @ mene oe Ss Caled O80) awRoo eet te eee Re tiger eg nO Macreee en ete Fle Edt Yew Favorites Tool Hep civ: 202 [item 10.6018 |[ [DI P=) [an] oes] (slum) ‘A 42,year-old woman with a history af pemicious anemia camesto the physician complaining of incieased anxiety, hoart palpitations, heatintolorance, unewalained weight loce, and multi dally aawol ravernents. She has not had a periodin 4 morths. On physical examination, the patient is found to have a goter, a thyroid uit, and mile proptasis. Lahoratary studies shaw elevated trincthyrenine and tree thyroxine levels, and an undetectable theroid -siimulating hormone. Which of the following is the most ikeiy etiology ofthis patient's ciseasa? A. Autoimmune. stimulation cf tryrcid-stimulating hormone receptors B Idiopathic replacement of thyroid tiesue with fibrous tissue ©.Thyroid adenoma D. Thyroid hormone-producing overian teratoma E.Vial infection leading to dastuction ofthyroid tissue 13 : 16 z 16 tt 18 Block EndFle Edt Yew Favorites 13 14 16 16 a tt i Block End Taok Hep Ze reams or78 [>] Ville) The correct answer is A. This patient presents as a classic cas of Graves' disease. The mechanism of Graves’ cisease canters on thyrad-stimulating IgG aniihodies that bingo thytolc-stmulating hormone (78H) receptors and lead to thyrald hormone production, Similar, slrrutation ofthe TSH receptor causes ylandular hyperplasia and enlargement characteristic ofthe gotter associated with Oraves'diseese Graves! disease is the mostcommon couse of thyrotoxicosis, Patients with this concition may havo othor autoimmune disoaces, such ac pomicious anomia or yo01 dlakotes rallius, and Fecuently prosent with arity, iitabiliy, tremor, heat nfclerance with sweaty skin, tachycardia and cardiac palnitations, weight ss, increased annette, fine hair, diarrhea, and amenanhea or oligomenorrhea, Otner suggestive signs include difuse goiter, proptosis, pericrbtal ederna, and thickened skin an the lower exremities. Lahoratoryvalues ate consistent with a hynerttyraid state, with increased thyroid hormone levels and decreased TSH levels Bis not correct. jdlopathic replacement of tyraid and surounding tissue with fibrous issue is seen In Riedel tnyroldils, pellents can present wih dysphagia, slider, ¢ysonea, and fypothrroidism, altiough rare than 50% cf patients are euthyroid, The disease can mimic thyroid cerchioma, which is high an the list of diferontal diagnoses for a pationt with Riedal's thyroiditis, Cis not correct. Most shytoid adenomas presentas soltary nodules and are usually nonfunctional Dis not correct. Thyroid harmane-producing cvatian teratomas are known es strum ‘vari a tumor consisting of thyroid tissue, These turnors can cause hyperthyroidism, but gven the patients history of autoimmune disease, Graves’ disease is the better answer choice Eis not couect. Viel infections such as mumps of coxsackievitus can lead to destruction ofthyroie tissue anc granulomatous inflammation, as seen in subacute granulomatous thyroiditis. Patients typically present with flu-like symptoms and thyroid tendamass and aain. The disease is typically self limited and can include a transiant hyperthyroid state ime o @ mene Chon) aaFle Edit vew Tae oO eon ean lbs merece eerie eee Favorites Tools Hep fb: 2048 [nem 11 ot 18 (

[VI p4)[tn] Se.) mame ‘A 43;year-old man with a history ofhypersaleernia and bilaterel hernianopsia presents to the emergency department ‘wih muscle woakness, lethargy, and watery diarrhea. Ho roporte briof opisodas of completo paralysis in his lowor exromitis. The nH of the patent's nasacasiric suction fuid is increased. An abdominal massis noted on CT sean, ‘The patients family history is positive farnumeraus endactine argan abnormalities. Which of the following isthe mostlikely cause ofthis patient's symptoms? A.Gastrinoma B.Ingulinoma ©. Medullary thyroid carcinoma D.Paneieatic adanocercinara E.viPoma 13 14 Explanation 15 16 tt 18 Block EndFle Edit vew Favorites Tools Hep 13 14 16 16 a tt i Block End ae a8 rem oF |e) [vf [uH Se) (siimia) [exstenaion] The correct answer is. This patisnthes clinical evdence of multiple endocrine eopiasia (MEN) ype |, whic can cause tumors in the "3 F's": the Pitutary gland, the Parathyroid gland, and the Pancreas, The MEN eyncrome follows an autosomal dominant pattern of nheriance, thus this patient's family history of mufiple endocrine ‘organ abnormalifies further supports this diagnosis. inthis natient, narathyrtd) invohement is suggested by hypercalcemia, and a ptutary adenoma is rast likely causinghis bilateral hernianopsia This patent has signs and symptoms consistent ‘with elevated levels of vasoactive intestiral peptide (VIP). VP acts on the out mucasa to promote Na+ secretion, ceusinga secretary diarthea VIP also stimulates K+ secretion in the calon, causing rypokslemia, which can lead ta the muscle weakness, tetany, and even period paralysis seen in this patient. Finally, VP Inhipits gastic acid secretion, leading to. hypochlorrydila, which caf be tested ay an elevated pH on nesogastric suction fluid. The majariy of ViPamas alise within the pancreas and ave tone type of pancreatic tumor seen in MEN | Ais not comrect. Gastrinamas are naa-f isket elltumais that commonly arise fam the pancreas and secrete gastrin, leading tnhynetsecretion of hycrochlorit cia, Aithough dastiinomas do sause diartiea and are associated with rrultinle endocrine Neoplasia | the pH ofthe nasagasbie suction Muid would be cecreased, rat increased, in a patient with a gastrinama Bis not correct. Insulinormas are islet cell tumors that secrete insulin, These tumars ae associated with Whipple's tac: hypaghcemis, symptoms orhypostycerria thai Include mental situs chenges, and relief 0! syinploins upon glucose administration Cis not correct. Medullary thyroid carcinorna is associated with increased levels of calcitonin, which rarely causes hypacalcornia and musclo woaknoss in those petients Medullary thytole estcinama is ascaciated with rnultiole endactine neoplasia (MEN) IA, and IIB but not with MEN. Dis not correct. Although an abdominal mass noted an CT scan could be a pancreatic adenocarcinoma, the patient's symptoms pointto the diegnasis of ViPome, @ mene eee eno! a) ay)eno eet te eee i egnr pie ie Fle Edt Yew Favorites Tool Hep fp: 2818 | mem 12 ot 18 |[- [vpn] Se.) (slim) ‘An 18-year-old waman is referred to @ specialist because she her periods have stopned. She reparts ovcesional outs ofnausea, vomiting, and genaralized woaknacc. Hot bload precoure ie 1 60/80 mn Ha; laboratary studiog show a serum K+ level of JL. Her ptysician remernbers that twa of the three adrenal hormones are atfacted inthis canditian, leaving onlyane functioning hormone. In which area atthe adienal gland is this ane harmane produced? ‘A Capsule B.Medulla ©.Zona fasciculata D.Zona glomeruiosa E.Zona reficular's 13 14 Explanation 15 16 tt 18 Block EndFle Edt Yew Favorites Block End 2] bone Naseem Charterer nee Meare eee aie te eet Taok Hep ip: 249 [rem 12 ore [lf |v fat Se) Tho correct anewor is D. 17-«-Hydrawylase, a form of congorital adranal hyporplasia, is characterized by dofets in glucocorticoid and sax steroid eynthasis. This Is coupled wih increased rrineralacarticoid prodicton due tothe increasec' flow of precursors, such as preanenalone and progesterone, through mineralocorticaid -yiaidina pathways. The resultant low serum cortisal and sax steroic levels with elevated rrineralocortivoid levels manifest clincaly with hypertension, hypokalemia, and female pheno'ype with na sequal maturation, Aldosterone is procucedin the zona glomerulosa, éldesterone syrthesis requires 2'-B-hydrorylase butnat 17-1 -hydrowyiase. Remember the mnemonic ‘Salt, Sugar, and Sey" for the layers of he acrenal collecand thell respective products. (siimia) [explanation | Alp not comrect. The capsule doesnot produce any hnammones: Bis not comreet. The medulla procuces catecholamines; neitrer 17-o-hydrowylase nor 21-fehydrmylase is requited forthe synthesis af eatechalamines. Cis not comrect. Cortisol is produced in the zana fasciculata ofthe adrenal cartex Cortisol synthesis requires 21-p-hydroxfase and 1 7-a-hyorowlase. Eis not correct, Sex horrranes are produced in the zona reticularis. Synthesis ofthe sex hormones requires 1f-c-nyuroxylase but not 21-3-ryaronylase. [FIRST AID] Adrenal steroids AGTH Keteco \e Dematse | @ mene Pied ae eee oiRee eee eee Negroes ee eres Fle Edt Yew Favorites Tool Hep ip: 3063 | nem 1g or 18 |i [vp [tH] 22.) (slim) ‘A 15-year-old woman presents te her gynecclogist 13 mantis after having her fist child. She reaarts thai although she had ctopped react feeding hor chid at the age of morthe and nae stopped praducing roast milk, she had naticed that overthe pastmanth she has begun to have milky secretions from her nipples ayain. In addition she ststes that although she hac retumecito her normal menstrual cycle, her menstrual cycles has taken the form af oni rile spotting over the cast 1-2 months. \What visual field defect is this patent most likelyto nave? A Bitermporal hemisnopia Contralateral hamorymaus herrianopia ©. Contralsteral superior quadrantanopia D. Monocular sectoma E. Monocular visual loss 13 : 16 z 16 tt 18 Block EndTeeter eee Ra ee Meremmencnee yer Fle Edt Yew Favorites Tool Hep 1 IG) ee | item 13 of 18 SP Mieeales) (sielim) ‘A 15-year-old woman presents te her gynecclogist 13 mantis after having her fist child. She reaarts thai alihaugh she had stopped breast feeding her child at the age of UinionthS aiid had stopped producing breast milk, she had noticed that overthe pactmenth she has begun to have milly secretions from her nipples again. In addition she ststee that although she hac retumecito her normal menstrual cycle, her menstrual cycles has taken the form af onW rile spotting over the cast 1-2 months. \What visual field defect is this patent most likelyto nave? A Bitermporal hemisnopia Contralateral hamorymaus herrianopia ©. Contralsteral superior quadrantanopia D. Monocular sectoma E. Monocular visual loss Tho correct anewor is A. Tho patient has a prclactinoma of the fitutary gland causing the galactorrhea and supprecses her naimal menstrual cycle. Because atthe anatomic location ofthe pituttary glano, tumors in this area can compress the optic chiasm, causing damage to the crossing fibars and resulting biterporal hernianopia. Block End Bis not comrect. Contralateral hamorymous hemianapia is caused bylesions cf the optic tracts such as 1 cts, or demyelination Cis not correct. Contralaters| superior quadrantanopia is caused by lesions ofthe lemparal lobe thet aeu Ihe opt: radialions as they tavel fam Ine lateral geniculate nucleus to the oplic cortex, Dis not correct. Monocular ceatarna is caused by locions af the retina, net atthe -200ns ofthe optic nerve, chiar, or tracts. Eis not correct. lonoculsr visual loss is caused ty lesions of the entie retina or lesions io the optic nerve before crossing over accurs atthe chiasm, dl cone @ mene oe Ss Caled O80) awRoo eet te eee Re tiger eg nO Macreee en ete Fle Edt Yew Favorites Tool Hep = | reem 14 or 18 | ] vf )[ra0| Ses.) [siieii=) ‘A 1-year-old boy is brought io the emergency department after becoming less responsive following several bouts of, nausea and vorniting. Tho paiiont ic tachycardi: and ie broathing doaply and slow). Laboratory studios aro remarkaale fora serum pH of7.21, 2 serum glucase level ef 700 mafdL, a cerum HCO2- level of 16 mEaiL, and a serum anion gap af22 (normal 7-16).Intavenaus fiLide and insulin are administered, Wanagemant ofwhich afthe following elactolites is mosteritcal in this patient? Cane B.Cl C.Heo3. D.K+ E.Net 13 : 16 z 16 tt 18 Block EndFle Edit vew Favorites Tools Hep 13 14 16 16 a tt i Block End — rem 34 0038 | [> [vO] ce) [sim] [explanation | : come out ofthe cells, end their positive charge will be replaced by K+ ions moving Ais not correct. Ca2+ does not undergo insulin-rediated trenscellulsr shift, a8 fs the eace with K+; hance, corum levels of Ca2+ da nat fluctuate ta the same extont ‘with diabetic katoacidosts and insulin administration Calcium gluconate is gen administered to protect cardiornyocytes agains! arrhythmias that may result For abnormal serum K+ levels; s2rum Ca2+ levels per se are usually nat the concern in petients with ciabetic ketoacidosis. Bis not correct. Cl- dozs noi undergo insulin-mediated transcellular shits, as is the case wit Ke; hence, serum levels of Cl da notfluctuateta the seme edentwith diabetic ketoacidasis and insulin administration, Appropriate ‘luld resusctaton is generally sumiclent ta manage serurn Cl-levals in palleris who mayne dehydratec, fs not comrect, O03 does not undetuo insulin-mediated transcellularshits ais, the eace with K+, HCO2. levels afton narmalize with the carrastion at hyperglycemia ‘and fle aeminictraion wih dluresis of serum keloseids, HCO shauld oe Aciministered anly when serum HCO2- levels are lees thar 15 rE ql. Eis not correct, Na does not undergo insulin-mediated transcellular shifts, as is the case wit Ke, Setur levels of Na+ therefore danat fluctuate tathe samme extent with tabetic ketoacidosis and ineulin administration, Fluid resuscitation Is gexerally suficient ta manage serum Nat levels in patients who ray he dehydrated, @ mene eee eno! a) ay)Roo eet te eee Re tiger eg nO Macreee en ete Fle Edt Yew Favorites Tool Hep fap: 2860 | nem sor 18 || [vpn] Se.) mame ‘A cerlain endocrine disorder can leadto an elevated blood pressure, decreased K* levels, Nav andwater retenton, and éoctoased renin activily. Which of tho following is tha most likaly diagnasic? A Addison's disease B Hypotthyroidiem ©.Pheochramocvtama D.Primaty hyperaldasteronism E Secondaty hyperaldastarcnism z Explanation 13 14 16 16 tt 18 Block EndFle J bone Edt Yew Favorites Block End Taok Hep oe weemsor8 i>] Ville) Explanation The cortect answer ISD. Primary nyperaldosteronismn is most commonly csused ay an aldgsterone-pracucing adenoma of the adrenal gland. can also be found In patients with zona glomeulosa hyperplasia, The incieased levels of aldosterone lea to hypertension, Na+ and waterretenton, and hypakalemis. Increased blood pracsure and aldoctorano lovols can faed backard cause a doctoaced lave! of Serum renin, Serum renin levels help diferentiate between primary hymeralcosteronism, wih increased aldosterone and decreased renin levels, and secandaty nyreraldosteronism, wit increased aldosterone levels and increased renin levels, As not correct. Addison's cisease results rom adrenal alroaty and causes hypotunction cfthe edrensl clards Patients with Addison's disease display signs that ar the cpposite of those seen in ryperaidosteranism, including hypotension, hyponatiernia, and typerkalernia Bis not correct. Paierts with hyperthyreidism have heat intolerance, hyperactivity, ‘woight lose, chest pain/palptations, arrhythmia, diarthaa, hyporrofexta, fne hair, and warm, moist skin, Cis not correct. Patients with pheochromosytoma have insreased levels of epinentvine and norepinenhrine, which can lead to elevated blood pressure; however, Na+, Ke, and erin levels are net afected Eis not correct. Lab valuas in secandaty hyperaldasteronism wauld show hypeinatremis and hypokalemia with an increese in renin levels, Secondary hypetalcosteranisrn occurs In settings In which the Hdneys parceive Icw intravascular vyoume (renal ariery stenosis, chronic renal falure, chronic heartfaiure, cirrhosis), resulting in an overactive renin-engiotensin system that acts a3_a stmulus for aldosterane seoraticn, = @ mene Pied aeFle Edt Yew Favorites Block End ALERK :: Your prescriptio lbs merece eerie eee Taok Hep fp: 2049 | nem 6 ot 18 |<] [vpn] Se.) (slim) ‘A 59-year-old man with a hisiary of abesiy, myacerdial infarction, retnal detechment, and foat ulcers presents tothe ‘omargency dosartmantwith umbnase andtingling in his wor axtiomitios. He has koon receiving dialyoic for tho pact 2 years, His hemagiabin Ate leval ig Increased, Which of the fllowing deserioes the glamerular pathalogy mest likely seen an light microseany ofthis patient's Kicheys? A Diffuse capillary and basement membrane thickening B Enlarged hynercellular glemerul with neutrophils ©. Nedular glometulosclerosis with thickened basement membians D.Segmertal sclerosis with hyalinasis E.Wire-loog sppearance with subencothelial basement membrane deposits ExplanationFle 2] bone Edt Yew Favorites 13 14 16 16 it 18 Block End Naseem Charterer nee Meare eee aie te eet Taok Hep essa [remisor%e |) Lv IFj[an] 58) (silaiim) The correct answer is C. This patieni hes symptoms and a dlacnasis consistent with type 2 diabetes melitus. Type 2 diabetes melitus can cause a number of health prablame, inclucing small veccal dicease, retinopathy, nephrapathy, large vecsal atherscletosis, carmnaty artery disease, pevinheral vascular orclusive disease, cerebrovascular disease, neurnoathies, and cataracts. Hyperglycemia in these patients, as reflected by the increased hemoglobin A‘c level, can be atributed to a number of causes, including peripheral insulin resistance, impaired insulin processing, dysfunctional glucose detacton by B cells, or Impaired intracellular signaling, On light microscopy, kidneys affected by diabetes demonstrate nodular glomarulosclerosis, also known as Kmmeistisl-ilson disease, and a thickened glomarularbasement membrane. Als tot comect, Difuse capillary and basement membrane thickening is assoclaled with membranous. glomerulonephrits, Bis not correct. Enlarged hypereellular glomeruli with neutrophils can be found in acute neststrentecoccal glormerulonenhiitis Dis not correct. Seymental scleresis with hyalinasis fs seen in focal seomental lomarulosclerosis, Eis not correct. Slomerull demonstrating 2 wire-logp appearance with suberdothelil basementmembrane deposits ate seen in luaus neptrapatny. Glomerular Nephrltic syndrome—hematuria, hypertension, I= inflammation pathology oliguria, azotemia I. Acute postsireptacoccal glomerulonephritis— Most frequently seen in @ mene oe Bhieuioo a) ay)Fle Edit vew ALERx :: Your prescription to USMLE Success - Microsoft Internet Explorer Favorites Tools Hep 13 14 16 16 tt 18 Block End a 2048, | nem 17 ot 18 |[- [v4 )[ten] Se.) (slim) ‘A 4-year chile whose farrily arived inthe United States from China last month is brought to the pediatncian for @ chackup. On physical examination, the pationt ic fourd to be chart, rotbolled, and palo with a ruff face, a erctruding umbilicus, an¢ a pratuzeranttongus. The child shows claar cigns of significant mental retardation, Which of the Tollowing lanaratcry sis chauld be ordered farthis patient and what are the likely results? A Pituitary funetion tests: increased growth hommone and ACTH levels Pituitary function teste: ineveased growth harane level, decreased ACTH level ©. Thyroid function tests: decreased thyroid-stimulating hormone, increased triiodothyronine and thyroxine levels D. Thyroid function tests: incteased thyroid-stimulating hormone, decreased tniadothyronine and thyroxine levels E. Thyroid function tests: increased thyroid-stimulating hormone, increased titedothyranine and thyroxine levels ExplanationFle Fat Yew Favertes Took He rem s7 0818 |] > [vfs Se) (situa) [exstanaion] The cortect answer is D. This patients likely suffering fram endemic sretiniam due to. ceficiencyin dietary iodine, a disorder thatis still eamman in parts af he werld including China, Lack cf dietary iodine leads ta deviclentthyroid harmare production and thus hypathyroiciom, Thyroid harmane is eftical during) development and thus children who grow ua in iodine-ceficient areas may manifest skeletal end central netvcus system abnormaities, including short stature end mental retardation Unfortunately fortis child, ance the symdrome is olirically apparent, it cannot be reversed, Tryroid function tests woule show decreased levels oftriiodathyranine and thyroxine, and increased levels of thyroid-stimulatng hormone secondaryto the lack ofneyative feedback on the pitutary, thus confirming the diagnosis of primary : hypomnyroiaism, 13 Ais not correct. Cretinism is caused by defcient production of thyroid hormone its While decreaced negative feedback on the anteriarritutary leads te eloveted tryrcid : stimulating hormane lovals, te levale of growth hormone and ACTH eocrstion by tho 16 pituitary would net be atfectea 16 it Bis not correct. Cretin'sm is caused by defcient production of thyroid hormone While decteaced negative feedtack on the anterior pituitary leads to elevated thyroid 18 stimulating hormane levels, tie \evels of growth hormone and ACTH secrstion bythe Block End || Pituitarywould net be affect. Cs not comect. Elevated T2 and 74 levels, wih decreased tryreia-stimutating hortnone (TSH) levels, would be seen in arimary ryerttyroidisrn. This could be ‘caused by aulonornous {TSH secretion, as in atopic adenoma orby auloimmune antipody stimulation afthethyraid glard, a8 n Graves! disease. Eis not correct, An elevated thyroid-stireulating hormone (TS-) level, along with elevated thsrid hormone levels, suggests production of TSH that is urresnensive to negative feedvack fiom the increased levels ofthyroid hormone. These lad values could be szen ina patient with a TSH-secreting ptuitary adenoma, butweule net b> exected in a patient with cretinism, who would have elevated TSH levels, out decreased levels oftriodethyrorine and thyroxine, @ mene oo Bieta) aeFle Edit vew ee eS ee ae rege Os Wares en ete Favorites Tools Hep 2701 | nem is or1s [ [vp4[t0] 22.) mame ‘A 85-year-old woman comes to ner primary care rhysician complaining of progressive weakness and fatigue. On further questioning, che notos a recent waight gain and canctipatian ae wall ao canctant cubjostiva chills. Physical examination shows a mocarate nontender goiter. biopsy shows alymphocslic inflate. Which of tha following best describes this patient's thyroid-stirrutating hormone (TSH) and thyroid hornone levels relative to normal baseline values? Thyra chvice inaiatg t t 13 14 16 16 i 18 Block EndFle 2] bone Edit vew Favorites 13 14 16 16 it 18 Block End Taok Hep a reem1s or 16 | [> |v Ife a] ese) Explanation The correct answer Is. The vignette describes a classi history ror rypothyrotaismn caused by Hashimoto's thyroidtis. Ths primary hypathyroidism is characterized by reduced secretion ef hyreid normene, resulting in decreased levels offres and tatal thyroxine (T4) and increased levels of TSH due to the absence of negative feedback by 14 Ais not correct. in the setting of a primary hynothyroidism, loth total and free thyrorine levels should be decreased rater than increased, Bis not comrect. Sath totel and ‘tee thyroxine (74) levels should be decreased rather than incteased in setting cf primary hypothyroidism. An elevated 74 would otherwise result in decreased rather then increased TSH levels due to negate feectack, Furthermore, ree ard tota T¢ levels snauld vary in the same direction in fils seting, as therels no change Inthe oinding capaci ofthe proteins in the biood. Dis not correct. Hashimeto's thyroiditis inaicates that both total and free TA levels should ke deeraaced rathor than increased, while TSH lovele chauld ko incroaced) rather than decteasad Furharmara, fee ard total thyrovine levels should vary in the seme direction in his settng, as there is na change in he binding capatiy of the prateins in the blooc, Eis not correct. in @ primary hysatiytoidism such as Hashimoto's thyroiditis, the reduction offree and total yroxne levels in the blood should eliminate feedhack inhibtion cf TSH secretion, leacing to increased rather than dacteasec TSH levels in the blood, (siimia) Hypothyroidism Gold intolerance, hypoactivity, weight gain itique, 1 TSH (een eee oi Zhe) test for] @ mene a) ay)