Step 1 Express 2018-Endocrine

First Aid Express 2018 workbook: ENDOCRINE

page 1

Endocrine Questions EMBRYOLOGY 1.

Which structure connects the thyroid gland with the tongue in early embryos? (p 320) __________ ______________________________________________________________________________

2.

How can you you differentiate differentiate a thyroglossal thyroglossal duct cyst cyst from a branchial cleft cyst? (p 320) __________ ______________________________________________________________________________

ANATOMY AN ATOMY 3.

What are are the the three major zones of the adrenal cortex? cortex? Name the hormone secreted by each zone. (p 320) ________________________________________________________________________

______________________________________________________________________________ 4.

What are are the the two divisions of the pituitary gland? gland? List the hormones secreted by each division? (p 321) ________________________________________________________________________

5.

Where are the cell bodies that produce produce the hormones released by the posterior posterior pituitary gland? (p 321) _______________________________________________________________________

6.

What are are the the three major cell types in the Islets of of Langerhans? Name the the hormone hormone secreted secreted by each cell. (p 321) ________________________________________________________________

______________________________________________________________________________

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PHYSIOLOGY 7.

Which two cell types have their glucose transport primarily controlled by insulin? By which specific glucose transporter? (p 322) _______________________________________________________

8.

What test will allow you to distinguish between high endogenous and high exogenous insulin? (p 322) ________________________________________________________________________

9.

Fill in the blanks and choose the correct answers to complete the mechanism by which β cells secrete insulin. (p 322) I.

Glucose enters the cell via ___________transporter.

II.

Glucose is catabolized, raising intracellular ATP.

III.

ATP-dependent __________ channels ___________ (open/close), causing ___________ (depolarization/hyperpolarization) of the cell membrane.

IV.

Voltage-gated ____________ channels ___________ (open/close).

V.

____________ enters the cell, disinhibiting the release of insulin-containing vesicles docked at the cell membrane.

VI. 10.

Insulin is exocytosed into the bloodstream.

Which two molecules control the secretion of prolactin? Which hormone does prolactin control the secretion of? (p 323) _____________________________________________________________ ______________________________________________________________________________

11.

What are the effects of antidiuretic hormone (vasopressin) on fluid volume and serum sodium concentration? Which of these is unique to ADH? (p 325) ___________________________________ ______________________________________________________________________________

12.

For each of the congenital bilateral adrenal hyperplasias in the chart, indicate whether blood pressure and sex hormone levels are increased or decreased. (p 326) Disease

Blood Pressure

Sex Hormones

11β-hydroxylase deficiency 17α-hydroxylase deficiency 21-hydroxylase deficiency



13.

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What enzyme catalyzes the conversion of testosterone to estradiol? What enzyme catalyzes the conversion of testosterone to DHT? (p 326) ___________________________________________

14.

Describe the regulation of cortisol secretion, including the relevant anatomic locations, cell types, and trophic hormones? (p 327) ____________________________________________________ ______________________________________________________________________________

15.

Where does the inactive form of vitamin D come from? Where do the two hydroxylation steps required to activate vitamin D occur? (p 328) __________________________________________

16.

PTH _______________ (increases/decreases) serum calcium levels and _______________ (increases/decreases) serum phosphate levels. Vitamin D _______________ (increases/decreases) serum calcium level and __ _____________ (increases/decreases) serum phosphate levels. (p 328)

17.

How do T3 and T4 control the body’s metabolic rate? (p 329) ______________________________ ______________________________________________________________________________

18.

What is the difference between thyroid-binding globulin and thyroglobulin? (p 329) _____________ ______________________________________________________________________________

19.

Increased levels of sex hormone–binding globulins _______________ (increase/decrease) free testosterone levels in men and _______________ (increase/decrease) free testosterone levels in women. (p 329)

PATHOLOGY 20.

What is the most common cause of Cushing syndrome? (p 331) __________________________

21.

For a patient who is not taking steroids, what are other potential causes of Cushing syndrome? (p 331) ________________________________________________________________________

______________________________________________________________________________ 22.

What are the common clinical manifestations of Cushing syndrome? (p 331) _________________ ______________________________________________________________________________


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23.

How is Cushing syndrome diagnosed? (p 331) _________________________________________

24.

Is hyperkalemia seen in primary or secondary adrenal insufficiency? (p 332) __________________

25.

What are the three common causes of Waterhouse-Friderichsen syndrome? (p 332) ___________ ______________________________________________________________________________

26.

What is the “rule of 10’s” for pheochromocytoma? What is the cell of origin for this tumor? (p 334) ______________________________________________________________________________ ______________________________________________________________________________

27.

What are the signs and symptoms of pheochromocytoma? (p 334) _________________________ ______________________________________________________________________________

28.

What is the primary symptom of the VIPoma neuroendocrine tumor, which secretes vasoactive intestinal peptide? (p 334) __________________________________________________________

29.

Compare and contrast the characteristics of hypothyroidism vs hyperthyroidism, using the chart. (p 335)

Sign/Symptom

Hypothyroidism

Hyperthyroidism

Activity level Bowel movements Cardiovascular changes Edema Free T4 Hair texture Reflexes Skin changes T3 uptake Temperature Total T4 TSH level Weight 30.

List five diseases characterized primarily by hypothyroidism. (p 336) _______________________ ______________________________________________________________________________



31.

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What is the difference between de Quervain thyroiditis and Riedel thyroiditis? (p 336) __________ ______________________________________________________________________________

32.

List two diseases characterized primarily by hyperthyroidism. (p 337) _______________________ ______________________________________________________________________________

33.

Name four types of thyroid cancer. Which is most common? (p 338) ________________________ ______________________________________________________________________________

34.

What is the Chvostek sign? (p 339) __________________________________________________

35.

Primary hyperparathyroidism is characterized by _______________ (increased/decreased) calcium levels and _______________ (increased/decreased) alkaline phosphatase, whereas secondary hyperparathyroidism is characterized by _______________ (increase/decreased) calcium levels and _______________ (increased/decreased) alkaline phosphatase. (p 340)

36.

What does the mnemonic “stones, thrones, bones, groans, and psychiatric overtones” stand for? (p 340) ________________________________________________________________________

______________________________________________________________________________ ______________________________________________________________________________ 37.

How is diabetes insipidus diagnosed? (p 342) _________________________________________

38.

What are the causes of SIADH? (p 342) ______________________________________________ ______________________________________________________________________________

39.

What are the differences between DI and SIADH? (p 342) ________________________________ ______________________________________________________________________________

40.

What are the acute manifestations of diabetes mellitus type 1? (p 344) ______________________ ______________________________________________________________________________

41.

What are the chronic manifestations of poorly controlled diabetes? (p 344) ___________________ ______________________________________________________________________________


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42.


Compare and contrast the characteristics of type 1 vs type 2 diabetes, using the chart. (p 345) Type 1

Type 2

Associated with obesity Genetic predisposition Glucose intolerance Ketoacidosis Need for insulin Primary defect Sensitivity to insulin Typical age of onset

43.

How can patients with diabetic ketoacidosis be recognized by their breath? (p 345) ____________ ______________________________________________________________________________

44.

What are the signs and symptoms of carcinoid syndrome? (p 346) _________________________ ______________________________________________________________________________

45.

In the chart, check which components are involved in the multiple endocrine neoplasias. (p 347) MEN 1

MEN 2A

MEN 2B

Pancreas Parathyroid Pituitary Pheochromocytoma

PHARMACOLOGY 46.

Name the three varieties of fast-acting insulin. What is the main use of fast-acting insulin compared to long-acting insulin? (p 348) ___________________________ ___________________________ ______________________________________________________________________________ ______________________________________________________________________________



47.

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What is the most feared complication of metformin? Which patients have the highest risk? (p 348) ______________________________________________________________________________

48.

Among insulin, metformin, sulfonylureas, and glitazones/thiazolidinediones, which can cause hypoglycemia if taken in excess? (p 348) _____________________________________________

49.

Which drugs are used to treat hyperthyroidism? (p 349) _________________________________

50.

Which drugs are used to treat hypothyroidism? (p 349) __________________________________

51.

Which drug is used to treat hyperphosphatemia? (p 350) _________________________________


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An swers EMBRYOLOGY 1.

Thyroglossal duct (a common site of ectopic thyroid tissue).

2.

A thyroglossal duct cyst will move with swallowing whereas a branchial cleft cyst will not.

ANATOMY 3.

Zona glomerulosa produces aldosterone, zona fasciculata produces cortisol, and zona reticularis produces sex hormones.

4.

Posterior pituitary: ADH (vasopressin), oxytocin. Anterior pituitary: FSH, LH, ACTH, TSH, prolactin, GH, and β-endorphin. MSH is secreted from intermediate lobe of pituitary.

5.

The hypothalamus.

6.

β cells produce insulin. α cells produce glucagon, and δ cells produce somatostatin.

PHYSIOLOGY 7.

Skeletal myocytes and adipocytes; by the GLUT4 transporter.

8.

C-peptide is absent if the source of insulin is exogenous and present in high levels if the patient has an insulinoma.


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9. I.

Glucose enters the cell via GLUT-2 transporter.

II.

Glucose is catabolized, raising intracellular ATP.

III.

ATP dependent potassium channels close, causing depolarization of the cell membrane.

IV.

Voltage-gated calcium channels open.

V.

Calcium enters the cell, disinhibiting the release of insulin-containing vesicles docked at

the cell membrane. VI. 10.

Insulin is exocytosed into the bloodstream.

Dopamine inhibits prolactin release; TRH stimulates. Prolactin inhibits GnRH, thus inhibiting the hypothalamic-pituitary-gonadal axis.

11.

ADH leads to increased fluid volume and decreased serum sodium concentration. Of the two, decreased serum sodium concentration and osmolality is more unique to ADH (aldosterone also increases fluid volume).

12. Disease

Blood Pressure

Sex Hormones

11β-hydroxylase deficiency

↑

↑

17α-hydroxylase deficiency

↑

↓

21-hydroxylase deficiency

↓

↑

13.

Aromatase; 5α-reductase.

14.

CRH stimulates release of ACTH in anterior pituitary, which prompts cortisol production in the zona fasciculata of the adrenal cortex.

15.

Inactive Vitamin D is absorbed from the diet or is synthesized in the skin when exposed to sunlight. Activation of Vitamin D requires hydroxylation in the liver, then the kidney.

16.

Increases; decreases; increases; increases.

17.

By increasing Na+/K+-ATPase activity, which increases oxygen consumption, respiratory rate, and body temperature.


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18.


Thyroid-binding globulin is a transport protein that carries T4 and T3 through the bloodstream (because they’re lipophilic). Thyroglobulin is a large precursor molecule synthesized b y thyroid follicles that is used to generate multiple T4 and T3 molecules.

19.

Decrease; decrease.

PATHOLOGY 20.

Exogenous corticosteroids.

21.

Cushing disease (pituitary adenoma): 70%; ectopic ACTH (eg, small cell lung cancer): 15%; adrenal tumor: 15%.

22.

Weight gain (truncal obesity), moon facies, buffalo hump, skin thinning, striae, hypertension, hyperglycemia, osteoporosis, amenorrhea, and immunosuppression.

23.

Dexamethasone challenge.

24.

Primary adrenal insufficiency.

25.

Septicemia due to N meningitidis bacteremia, DIC, and endotoxic shock.

26.

10% are malignant, 10% are bilateral, 10% are extra-adrenal, 10% calcify, and 10% occur in kids. Chromaffin cells are the cells of origin for pheochromocytoma.

27.

Elevated blood Pressure, Pain (headache), Perspiration, Palpitations (tachycardia), and Pallor. These “5 P’s ” are episodic.

28.

Secretory diarrhea.


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29. Sign/Symptom

30.

Hypothyroidism

Hyperthyroidism

Activity level

↓

↑

Bowel movements

Constipation

Diarrhea

Cardiovascular changes

Bradycardia; dyspnea on exertion

Chest pain, palpitations, arrhythmias

Edema

Myxedema

Pretibial myxedema

Free T4

↓

↑

Hair texture

Coarse, brittle

Fine

Reflexes

↓

↑

Skin changes

Dry, cool skin

Warm, most skin

T3 uptake

↓

↑

Temperature

Cold intolerance

Heat intolerance

Total T4

↓

↑

TSH level

↑ (if primary)

↓ (if primary)

Weight

Weight gain (low appetite)

Weight loss (high appetite)

Hashimoto thyroiditis, postpartum thyroiditis, cretinism, de Quervain thyroiditis, and Riedel thyroiditis.

31.

de Quervain (subacute) thyroiditis is a self-limited type of hypothyroidism that follows a flu-like illness. Riedel thyroiditis involves fibrous replacement o f the thyroid.

32.

Graves disease, thyrotoxicosis, and toxic multinodular goiter.

33.

Papillary thyroid carcinoma (most common), follicular, medullary, and anaplastic.

34.

In hypoparathyroid patients, tapping of the facial nerve causes the facial muscles to contract.

35.

Increased; increased; decreased; increased.

36.

Renal calcium stones, polyuria (thrones), osteitis fibrosa cystica of bones, neuropsychiatric disturbances (“psychiatric overtones”), and abdominal complaints (groans due to constipation).

37.

Water deprivation test: urine osmolality doesn’t increase in response to water deprivation. Response to desmopressin can distinguish between central and nephrogenic DI.


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38.


Ectopic ADH (eg, small cell lung cancer), CNS disorder/head trauma, pulmonary disease, and drugs such as cyclophosphamide.

39.

DI denotes lack of ADH; SIADH denotes too much ADH. DI is characterized by intense thirst and polyuria, with high serum osmolarity and low urine concentration. SIADH is characterized by excessive water retention, with high urine osmolarity and l ow serum osmolarity.

40.

Polydipsia, polyuria, polyphagia, weight loss, DKA (type 1), and hyperosmolar hyperglycemic state (type 2).

41.

Retinopathy, glaucoma, cataracts, nephropathy, atherosclerosis, CAD, peripheral vascular occlusive disease, neuropathy, and gangrene.

42.

43.

Type 1

Type 2

Associated with obesity

No

Yes

Genetic predisposition

Weak

Strong

Glucose intolerance

Severe

Mild to moderate

Ketoacidosis

Common

Uncommon

Need for insulin

Always

Sometimes

Primary defect

Destruction of β cells

Increased resistance to insulin

Sensitivity to insulin

High

Low

Typical age of onset

<30 years

>40 years

Increased ketogenesis results in accumulation of acetone and other ketones; when exhaled, acetone gives breath a fruity odor.

44.

Diarrhea, cutaneous flushing, asthmatic wheezing, and right-sided valvular disease.

45.

MEN 1

Pancreas

√

Parathyroid

√

Pituitary

√

Pheochromocytoma

MEN 2A

MEN 2B

√ √

√



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PHARMACOLOGY 46.

Insulin aspart, lispro, and glulisine. Unlike long-acting insulin, which is used to maintain a normal basal insulin level, fast-acting insulin is taken with meals to address abnormally elevated postprandial glucose.

47.

Lactic acidosis, especially in patients with renal insufficiency) or B12 deficiency.

48.

Insulin and sulfonylureas can cause hypoglycemia if taken in excess

49.

Propylthiouracil and methimazole.

50.

Levothyroxine (T4) and liothyronine (T3).

51.

Sevelamer.


Step 1 Express 2018-Endocrine

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