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Brown Medical School Bio 351 Endocrinology-Pathophysiology Systemic Pathology Organ System Pharmacology
Brown Medical School Bio 351 Endocrinology-Pathophysiology Systemic Pathology Organ System Pharmacology
Bio 351
Endocrinology-Pathophysiology
Systemic Pathology
Organ System Pharmacology
Final Exam
Course Leaders
James Hennessey, MD
Elaine Bearer, MD-PhD
Robert Patrick, PhD
Pathology
Pharmacology
A. Metyrapone test
B. Midnight salivary cortisol
C. Cortrosyn stimulation test
D. 24 hour urine collection for free cortisol
E. None of the above
2. The most likely cause of adrenal insufficiency in this patient would be:
A. Autoimmune adrenalitis
B. Tuberculosis
C. Pituitary tumor
D. Adrenoleukodystrophy
E. None of the above
Laboratory data includes: pH 7.18 (Nl 7.36-7.49), Glucose 574 (Nl < 100 mg/dL),
Potassium 4.9 (Nl 3.5-5.1 meq/L), serum and urine ketones strongly positive.
6. Of the following, the most important factor in the patient’s production of ketone bodies
is:
7. Potassium therapy:
A. Bicarbonate
B. Insulin
C. Normal saline
D. L-thyroxine
E. All of the above would be unnecessary
9.The following 3 questions refer to the image below:
12.At this stage in this disease progression, there would most likely be
A 78 year old woman comes to your office for her annual check-up accompanied by her
daughter. Reviewing her intake data, you find that she has lost 15 pounds over the past
year even though she was previously at her ideal weight. In questioning the patient, you
find that her weight loss has been more acute, i.e., over the past 3 months due to a bout
with pneumonia. On exam, you notice that her dentures are fitting poorly and her gums
are inflamed. The patient’s daughter tells you that her mother has only been consuming
cream soups, cream of wheat, mashed potatoes, jello and beverages.
13. Proportionately, the more acute the weight loss, especially if there is very little
physical activity during the same period of time, the more:
14. This patient’s acute weight loss is superimposed on the muscle loss that naturally
occurs with age. This muscle loss with aging, known as sarcopenia, occurs at a rate of
1% loss per year after the age of:
A. 65
B. 45
C. 55
D. 75
E. 95
15. In evaluating her current diet you ask the patient and her daughter what beverages the
patient has been drinking and they state that she drinks mostly tea with a little sugar and
some grape juice. You realize the diet is grossly inadequate in a broad spectrum of
nutrients. How would you proceed?
16. Which test is the most likely to reveal the etiology of her goiter?
17. Following this patient’s story further, a urine pregnancy test returns positive. You
estimate, based on the hCG level that she is about 6 weeks pregnant. Which of the
following concerns would apply to her baby?
A. Even if the patient is hypothyroid, the baby should be fine as it’s thyroid should be
able to
produce thyroxine sufficient for it’s needs.
B. In this circumstance, urine pregnancy tests are notoriously inaccurate and the patient is
actually highly unlikely to be pregnant.
C. Fetal outcomes are independent of maternal thyroid status and genetically determined.
D. Fetal thyroid function does not develop until later in gestation and the baby’s
development would be dependent on thyroid hormone transferred from the mother.
E. Passive transfer of TSH receptor antibodies from mother to baby does not effect fetal
thyroid function as the placenta inactivates the immunoglobulins.
A. Free T4
B. FreeT4 and free T3
C. TPO antibodies and free T4
D. TSH and free T4
E. TSH
19. All of the following statements concerning L-T4 are correct EXCEPT:
A. L-T4 has a longer half-life compared to L-T3
B. Most (>50%) of the L-T4 in the blood is protein bound
C. Calcium decreases L-T4 absorption from the GI tract
D. Whenever L-T4 is used in thyroid therapy, L-T3 must also be administered
E. The thyroid gland normally contains more LT-4 than LT-3
A 53-year-old woman reports a 6-week history of palpitations, heat intolerance and
anxiety. Her primary care physician’s associate has prescribed a B-blocker for her over a
weekend call and she has noticed increased frequency of bowel movements. On physical
exam, her resting pulse rate is 112 beats per minute (BPM), blood pressure is 145/80
mmHg and she appears flushed and distracted. Eye exam reveals an alert look without
obvious proptosis; her thyroid is enlarged and feels somewhat nodular. Heart exam is
note worthy for an irregularly irregular rhythm and EKG reveals atrial fibrillation at a
rate of 115 BPM. Thyroid function tests reveal a TSH of <0.01 uU/ml (nl 0.5-4.0), Free
T4 of 2.4 ng/dl (nl 0.8-1.8). She is referred for a 123-I uptake and scan which reveals an
uptake of 58% at 24 hours (nl 15-30%) and a homogeneous tracer distribution interrupted
by an large area of no uptake in the left lower pole region. A thyroid ultrasound reveals
heterogeneous consistency of the right lobe and upper left lobe with a 3.5 X 3.4 X 2.8-
centimeter hypoechoic nodule with what appear to be microcalcifications in the lower left
lobe.
20. In regard to the thyroid function abnormality in this patient’s case, which of the
following are likely?
A. This patient is presenting with classic hypothyroid symptoms, most likely due to
iodine deficiency.
B. At this age, tachycardia is likely due to underlying heart disease and not likely
associated with thyroid dysfunction.
C. All of the thyroid function abnormalities can be best explained by the typical
presentation of the left lower lobe nodule.
D. This patient likely has autoimmune thyroid disease.
E. This patient likely has a hypothalamic process which has resulted in pituitary
production of TSH which is over stimulating thyroid hormone production.
21. The image above demonstrates key features of this disease which include all of the
following EXCEPT
22. The patient described above is rendered euthyroid with appropriate therapy. She
returns 6 months later after a repeat ultrasound is performed which reveals that her
nodule has increased in size by approximately 25%. The appearance of
microcalcifications is persistent and the patient is referred for an appropriate diagnostic
intervention. Which of the following statements is true in regard to this nodule?
A. The enhancement of the absorption of fat through the activation of lipase in the gut.
B. The combined effect of serotonin reuptake inhibition and increased serotonin
production.
C. The reuptake inhibition of norepinephrine and dopamine.
D. Direct stimulation of Leptin secretion
E. Indirect suppression of thyroxine production
A. Serotonin
B. Lipase
C. Dopamine inhibiting substance
D. Leptin
E. Adipocyte stimulating factor
A. The gastric pouch procedure should be used prior to utilizing the Roux-en-Y gastric
bypass procedure.
B. Roux-en-Y gastric bypass is a more complex procedure with more severe side
effects and typically more complications than the gastric pouch procedure.
C Patients with a BMI greater than 40 are best treated through the use of surgical
intervention.
D. Patients with BMI less than 30 Kg/m2 are the best candidates for bypass
E. None of the above
A 16 year old girl presents to your office for the evaluation of weight gain. She denies
overeating but loves soda and juice, watches 5 hours of TV per night, and is active only
in gym class at school. Her past history is unremarkable and family history reveals that
several members of her family are obese and have type 2 diabetes. She does not take any
medications at present. Her menses are regular, and the remainder of the review of
systems is negative. On physical examination, her height is 157 cm (25th percentile),
weight 97 kg (>95th percentile), BMI 39.4 (>95th percentile). Her BP is 110/70. Her
obesity is generalized. She has dark thickening of the skin around her neck. Her thyroid is
of a normal size and texture. Her liver span is normal. She has completed puberty and has
some terminal hair above her lip, and along her linea alba. The remainder of the
examination is normal.
A. Hypothalamic dysfunction
B. Hypothyroidism
C. Leptin deficiency
D. Exogenous obesity
E. Cushing’s Syndrome
28. Given the physical findings above, which potentially reversible complication is
already present?
A. Sleep apnea
B. Hypertension
C. Insulin resistance
D. Hepatic cirrhosis
E. Type IV hyperlipidemia
A. The initiation of Orlistat by giving the patient a prescription for this medication at this
visit.
B. Referral to a bariatric surgeon to be evaluated for a Roux-en Y procedure.
C. Obtain thyroid function studies as part of the bariatric evaluation of this patient.
D. Have the patient start an exercise program and follow up in 6 months.
F. Prolonged fasting should be instituted as soon as possible.
A 49 year old man is referred at the recommendation of his ophthalmologist, who
reported findings consistent with proliferative diabetic retinopathy. The patient has
noted blurred vision, polyuria, polydypsia, and weight loss of about 10 lbs during the past
3 months. History and system review are otherwise unremarkable. Clinical exam is
significant for weight of 184 lbs, BMI 27, decreased sensation in the feet by
monofilament testing and absent Achilles reflexes.
Laboratory data:
Glucose 374 mg/dL (Nl < 100)
HbA1c 11.8% ( Nl 4.3-5.8)
Electrolytes normal
Creatinine 1.2 mg/dL (0.4-1.3 mg/dL)
BUN 20 mg/dL (Nl 6-24 mg/dL)
Urine microalbumin 445mg/gram creatinine (< 300)
31. At the end of his initial visit, the patient requests information regarding the causes of
diabetes and potential benefits of treatment. Which of the following statements is true?
A. Cellular damage in diabetes results from increased formation of prostacyclin and nitric
oxide and decreased formation of growth factors such as vascular endothelial growth
factor
B. Increased reactive oxygen species produced by insulin resistance and glucagons
excess is the major cause of diabetic microvascular disease
C. The patient’s risk of developing microvascular disease is directly related to his level of
future glycemic control
D. No clinical trials have examined the potential benefit of glycemic control in
preventing diabetic complications
E. Treatment of hypertension does not affect the risk of diabetic microvascular disease
32. Assuming the patient is not currently using insulin, it would be least appropriate
to
add which of the following to his current therapy:
A. Pramlintide
B. Insulin
C. Sulfonylurea
D. Metformin
E. Sulfonylurea
Fundoscope exam of the retina might reveal the image shown above.
33. These changes in the retina are primarily a consequence of all of the following
complications of diabetes EXCEPT
A. At this point, her future risk of undergoing an amputation of some type is about 5%
C B. Risk factors for ulceration and amputation include tobacco use and peripheral
vascular disease
C. The risk of developing foot ulcers is not related to level of glycemic control
D. Women with diabetes are less likely to develop coronary heart disease or stroke than
diabetic males of similar age
E. Intensive insulin therapy will improve glycemic control but will also have an
adverse effect on wound healing
35. Of the following statements regarding diabetes and renal function, which is most
accurate?
A. Because of the marked proteinuria, the patient very likely has non-diabetic renal
disease.
B. Clinical studies indicate that most diabetics have a decreased GFR at the actual time
of onset of their diabetes.
C. At least 90% of patients will develop diabetic nephropathy if they have diabetes for
20 years or more.
D. Diabetic nephropathy is associated with increased risk of cardiovascular disease
even in the early stages.
E. Caucasians with diabetes are at greater risk of developing end-stage renal disease
than Afro-Americans or Latinos
. 36. Potential problems with the patients current two-shot insulin regimen would be
likely to include:
40. A fine needle aspiration of a 2 cm thyroid mass in a 30 year-old woman contains cells
with enlarged clear nuclei, prominent nuclear grooves and nuclear pseudoinclusions. The most
likely diagnosis:
A.Follicular adenoma
B.Papillary carcinoma
C.Undifferentiated (anaplastic) carcinoma
D.Medullary carcinoma
E.Adenomatous (hyperplastic) nodule
41. Which of the following statements concerning medullary thyroid carcinoma is true:
A.Most common type of thyroid cancer among individuals exposed to irradiation in childhood.
B.Heritable forms of this tumor have an autosomal recessive pattern of inheritance.
C.Heritable forms of this tumor are commonly associated with pheochromocytomas.
D.Pituitary tumors are found frequently in association with these tumors.
E.Are derived from follicular cells of the thyroid.
A 42-year old woman presented with longstanding tingling and numbness of her hands
and fingers, and intermittent leg cramps. Ten years ago, she had neck surgery for
removal of a goiter. Physical examination was positive for bilateral cataracts and positive
Chvostek and Trousseau signs.
Laboratory test results were as follows:
BUN 20 mg/dl (Nl 6-20)
Creatinine 1.0 mg/dl (Nl 0.4-1.3)
Albumin 4 gm/dl (Nl 3.6-4.4)
Calcium 7.0 mg/dl (Nl 8.5-10.5)
Phosphate 5.0 mg/dl (Nl 3-4.5)
Mg 1.8 mg/dl (1.3-1.9)
1,25-OHD 20 pg/ml (Nl 20-60)
25-OHD 30 ng/ml (Nl 30-80)
PTH 10 pg/ml (Nl 20-71)
A. Magnesium supplements
B. Vitamin D
C. Thiazide diuretic
D. PTH injections
E. Calcium gluconate 1 gm daily
44.A specific diagnosis of follicular carcinoma of the thyroid requires the presence
of:
46.In addition to hydration with intravenous isotonic saline solution, which of the
following
would be most effective in lowering his serum calcium level?
A. Furosemide
B. Hydrochlorothiazide
C. Zoledronic acid
D. Prednisone
E. Calcitonin
True-False
47. Tumors with the morphological and clinical features of pheochromocytomas may
arise in a variety of extra-adrenal sites.
48. Most adrenal tumors associated with the overproduction of aldosterone are
malignant.
49. Some cases of adrenal hyperplasia may be associated with decreased production
of aldosterone and cortisol.
Following a routine physical examination, a 69-year old male is noted to have a serum
alkaline phosphatase level which is twice normal. He is asymptomatic. His liver
function
tests are otherwise normal. Serum calcium and phosphate levels are normal.
A. Primary hyperparathyroidism
B. Bone metastases
C. Osteomalacia
D. Paget’s disease of bone
E. Secondary hyperparathyroidism
51. Which of the following abnormalities is present typically in patients with type
2A multiple endocrine neoplasia:
A. Etidronate
B. Nasal calcitonin
C. No therapy indicated at this time
D. Risedronate
E. Oral pamidronate
A 60-year old male complains of back pain and fatigue. Resting pulse is 110 and there is
tenderness over the lumbar spine. Laboratory data reveal a hematocrit of 27% (Nl 32-
45), serum calcium of 12.0 mg/dl (Nl 8.5-10.5), a normal serum alkaline phosphatase,
and serum protein electrophoresis shows a monoclonal gamma globulin spike. Skeletal
X-rays reveal severe demineralization.
A. Primary hyperparathyroidism
B. Multiple myeloma
C. Severe osteoporosis
D. Sarcoidosis
E. Paget’s disease
A 58-year old white female presents with mild back pain. After lifting her 25 pound
grandson, she experienced sharp and severe pain in the center of her back. General
health had been good. She was taking no medications. Menopause occurred at 51 years
of age and she received hormone replacement therapy for less than a year. She had been
smoking a pack per day for 20 years. Milk intake was negligible. Physical examination
was normal except for a mild to moderate thoracic kyphosis. Blood chemistry profile,
CBC and serum 25-OHD were normal. Thoraco-lumbar spine x-rays revealed two
thoracic vertebral compression fractures.
A. Usually malignant
B. Affected patients normally present with hyperthyroidism
C. The most common subtype contains prolactin
D .Composed of cells with squamous differentiation and areas of cyst formation
E. Most common tumor arising in the posterior lobe of the pituitary
59. A needle biopsy of a diffusely enlarged thyroid gland in a 50 year-old woman with
hypothyroidism shows extensive lymphoid infiltrates with reactive germinal centers and
multiple foci of oncocytic (Hurthle cell) change. The most likely diagnosis is:
As part of your evaluation you administer progesterone to the patient and she does not
have a withdrawal bleed.
60. Which of the following tests results would you anticipate finding?
A. High TSH
B. Abnormal imaging study of the brain (example: MRI)
C. Abnormal imaging study of the uterus (example: Hysteroscopy or
Ultrasound)
D. Low or normal FSH
E. High Testosterone
61. If you were to give this woman estrogen followed by progesterone for one
month which of the following would you expect?
63. Which of the following tests would most likely be abnormal on evaluation?
A. FSH
B. Prolactin
C. Progesterone
D. MRI of the brain
E. Imaging study of the uterus
64. A 35 year old woman has amenorrhea. You note increased facial hair, a deep
voice and a large right pelvic mass on examination. Which of the following ovarian
tumors could explain the clinical findings?
65. The most common cell types of origin for testicular and ovarian cancers are:
. 66. In this study, the combined (hormone) replacement therapy trial was stopped
prior to the planned completion because of which of the following findings?
68. Which of the following tests is most consistent with her history and the imaging
studies shown (with markedly enlarged and cystic ovary)?
A. Elevated testosterone
B. Elevated prolactin
C. Elevated TSH
D. Elevated CBC
E. Elevated FSH
69. You conclude that this patient has a virilizing tumor. Which of the following findings
on physical exam would be most consistent with this diagnosis?
A. Acne
B. Secondary sexual hair growth
C. Clitoromegaly
D. Moderate obesity
E. Increased muscle mass
F. Breast engorgement
42-year-old male presents to the ER with nausea, vomiting, and abdominal pain radiating
to the back. Past medical history is negative for alcohol use and gallstones. Physical exam
is unremarkable except for tenderness to palpation in the mid-epigastric region and
pustular lesions over his thigh and extensor surface of his arms consistent with eruptive
xanthoma.
70. The serum is found to have creamy white surface layer. Plasma lipid profile that best
describes this patient
A. Elevated Triglyceride
B. Elevated Low density lipoprotein
C. Elevated Lipoprotein (a)
D. Elevated High-density lipoprotein
E. Low Total Cholesterol
Laboratory testing reveals the following: Total testosterone = 147 ng/dL and 185 ng/dL
(280-1050) on two occasions; LH = 4 mIU/mL (3-15); FSH= 5.3 mIU/mL 3-18); and a
prolactin=71.9 ng/ml (5-20) His hematocrit 36.8 % (Nl 32-45) with normal indices.
Prostate Specific Antigen (PSA) =0.2 ng/mL (< 4.0) and HbA1C=6.0% (3.5-5.5). bone
densitometry (DXA) demonstrates a T score of –2.2 at the L-S spine (nl> -1.0) and –2.1
at the hip (nl> -1.0).
A. Hypogonadism
B. Diabetic neuropathy
C. Vascular disease
D. Anemia of chronic disease
E. Possible contribution of several or all of the above.
74. Which of the following would be least helpful as you evaluate this patient’s status?
76. Which of the following are NOT goals for prevention of diabetes complications?
A. Reduce weight
B. Control glucose
C. Control lipids
D. Use preventive practices for eyes, kidneys and feet
E. Control blood pressure
77. Which of the following nutrients should be minimized for diet therapy for a diabetic
patient?
A. Protein
B. Carbohydrate
C. Fat
D. Fiber
E. Alcohol
78. Which of the following is not usually considered to be the physician’s role in clinical
diet counseling for a diabetic patient?
79. Known nutrition related risk factors for development of Type 2 diabetes include:
A. Intake of carbohydrate
B. Excess intake of high glycemic index foods
C. Early introduction of high glycemic index foods
D. Exposure to cow proteins
E. Vegetable protein intake
PR is a 40 year old woman, who is 5’5” and 168 pounds (BMI = 28 Kg/m2). Her 75 g
glucose tolerance test showed that she is glucose intolerant, but she does not meet the
criteria for diabetes.
80. In consideration of diet to prevent diabetes for PR, the glycemic index of foods might
be considered. Glycemic index
81. Nutritional care for PR during her efforts to prevent diabetes will likely involve
82. Known nutrition related risk factors for development of Type 1 diabetes include
A. Intake of carbohydrate
B. Intake of high glycemic index foods
C. Early introduction of high glycemic index foods
D. Exposure to cow proteins
E. Exposure to toxins in breast milk
A 25 year old woman is brought to the Emergency Room by her husband. He reports that
she has been feeling weak and lethargic for about a week. This has progressively
worsened and, for the past 2 days, she has had nausea and vomiting. She is a fourth grade
teacher, and several of her students have been sick recently with a flu-like illness. On
review of systems by the ER physician, a history is obtained indicating that the patient
noted progressively increasing thirst starting approximately one week ago and has been
passing large volumes of urine, which require her getting up several times during the
night. The patient’s last menstrual period was approximately 3 weeks ago and, when
asked about this, she noted that she and her husband had decided to have a family and
therefore stopped using birth control about 2 weeks ago. Questions regarding the family
history reveal that her mother and a paternal aunt developed diabetes when they were
middle-aged. There is no other known family history of chronic diseases.
83. The most likely diagnosis to explain the metabolic state of this patient is:
A. Influenza
B. Type 1 diabetes
C. Type 2 diabetes
D. MODY diabetes
E. Gestational diabetes
84.The best test to confirm the specific disease responsible for the metabolic
abnormalities in this patient would be:
A. Influenza hemaglutinins
B. A determination of plasma hemoglobin A1c (HbA1c)
C. A plasma insulin level
D. A glucose tolerance test
E. Serum titers of anti-insulin, anti-GAD, and anti-islet antibodies
85. Of the following, the most appropriate longterm treatment for this patient’s
condition would be:
A. Sulfonylurea
B. Metformin
C. Thiazolidinedione
D. Basal-bolus insulin regimen
E. Diet and exercise only
A 50 year old man is admitted to the hospital for elective knee surgery. His medical
history is unremarkable except for long-standing obesity, with a current body mass index
of 35 kg/m2. His maximum waist circumference is 44 inches. As part of routine blood
testing on the morning of his operative procedure, his fasting blood glucose level is noted
to be 110 mg/dl. One month later, although asymptomatic, he is evaluated with a glucose
tolerance test (75 gm oral glucose after overnight fasting). The blood glucose values are
as follows:
87. t is considered important to screen this patient for other features that may be used to
diagnose the Metabolic Syndrome. Which of the following determinations is not required
to establish this diagnosis:
A. Blood pressure
B. Fasting triglycerides
C. LDL cholesterol
D. Waist circumference
E. Fasting blood sugar
. 88. Of
the following agents, which would be the least likely to cause weight gain
and hypoglycemia:
A. Sulfonylurea
B. Metformin
C. Thiazolidinedione
D. Basal-bolus insulin regimen
E. All cause weight gain and hypoglycemia
A 39 year old woman is seen by her primary care physician for a routine visit and
gynecological exam. She has a history of being “heavy” since adolescence. She delivered
her second child 2 years previously and comments to her physician that she “never lost
the weight” after that pregnancy and has gained weight since. She is 5 feet 2 inches tall
and weighs 170 lbs (BMI 31 kg/m2). She works as a bank teller and does not regularly
exercise. Her medical history and review of systems are otherwise unremarkable.
90. Her body weight status is associated with an increased risk of all of the following
EXCEPT :
A. Diabetes mellitus
B. Hypertension
C. Lung cancer
D. Hyperlipidemia
E. Breast Cancer
A 36-year-old man with three children 12, 10 and 8 years old, complains of headaches for
the past 3 months, double vision for 6 months and diminished libido for over a year. On
physical exam he is 5' 6" tall, weighs 142 lbs. and has normal blood pressure. He seems
to have some loss of peripheral vision and small soft testicles.
91. Of the following, which is most likely to be helpful in determining the cause of his
small soft testicles?
92. Of the following, which would be a likely cause of the clinical scenario outlined
above.
A. Testosterone injections
B. IM or subcutaneous FSH and hCG
C. Cabergoline
D. Aromatase inhibitors
E. A combination of testosterone and hCG
A 23 year old male from a rural community in Asia presents with a complaint of
infertility. On questioning he also reports a low libido and erectile dysfunction. His past
history is significant for mumps orchitis at age 19. On physical exam his testicles are
small and firm.
96. The most plausible mechanism by which adding a plant sterol to her diet will effect
this patient’s risk of a coronary event is:
97. The diet recommended to lower this patient’s risk of coronary heart disease is:
99. Gleason developed a grading system for prostatic carcinoma which involves:
101. Which of the following testicular tumor types is incorrectly associated with its
cell type of origin:
A. Embryonal carcinoma.
B. Seminoma.
C. Yolk sac tumor.
D. Sertoli cell tumor.
F. Leydig cell tumor.
103. Circulating FSH levels decrease following treatment with either leuprolide
(Lupron) or goserelin (Zoladex). Indicate the mechanism for this decrease in FSH.
A. Amiloride
B. Mitotane
C. Dexamethasone
D. Pegvisomant
E. Octeotride
105. In the treatment of Cushing's Syndrome, which of the following drugs acts
both by inhibiting adrenal steroid biosynthesis, and also as an androgen antagonist?
A) Ketoconazole
B) Metyrapone
C) Spironolactone
D) Mitotane
E) Aminoglutethimide