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ENDOCRINE 12TH EDITION

BOARD
REVIEW
S E R G E A . J A B B O U R , M D, P R O G R A M C H A I R

ENDOCRINE
SOCIETY
ENDOCRINE
BOARD
REVIEW
Serge A. Jabbour, MD, Program Chair
Professor of Medicine
Director, Division of Endocrinology,
Diabetes & Metaboiic Diseases
Sidney Kimmei Medical College
Thomas Jefferson University

Frances J. Hayes, MB BCh , BAO Michelle F. Magee, MD

Andrea D. Coviello, MD
Associate Professor of Medicine
Division of Endocrinology,
Metabolism, and Nutrition
Duke University School of Medicine
Natalie Cusano, MD, MS
Associate Professor of Medicine
Zucker School of Medicine
at Hofstra/Northweli
Director of the Bone
Metaboiism Program
Division of Endocrinology
at Lenox Hill Hospital
Ciinica! Director
Endocrine Division
Massachusetts General Hospital
Jacqueline jonklaas, MD, PhD, MPH
Professor
Division of Endocrinology
Georgetown University Medicai Center
Laurence Katznelson, MD
Professor of Neurosurgery
and Medicine
Division of Endocrinology
Director
MedStar Diabetes, Research
and innovation institutes
Professor of Medicine
Georgetown University
School of Medicine
Kathryn A . Martin, MD
Assistant Professor of Medicine
Harvard Medical School
Practicing Clinician
Massachusetts General Hospital
Senior Physician Editor,

Stanford University Endocrinology and Diabetes

UpToDate
Tobias Else, MD
Associate Professor
Division of Metabolism, Abbie L. Young, MS, CGC , ELS (D)
Endocrinology, and Diabetes Medical Editor
University of Michigan

Endocrine Society
2055 L Street NW, Suite 600, Washington, DC 20036
ENDOCRINE i
ma

1- 888 - ENDOCRINE © www.endocrine.org

 mm
m1
m
V/ f
SI
4
V

ENDOCRINE
Hormone Stfence ft? Health 4
v

The Endocrine Society is the world’s largest, oldest, and most

active organization working to advance the clinical practice of
endocrinology and hormone research. Founded in 1916, the :
Society now has more than 18,000 global members across a : / / /;/
.
range of disciplines The Society has earned an international L'

reputation for excellence in the quality of its peer- reviewed

journals, educational resources, meetings, and programs that
improve public health through the practice and science of : ;v V
endocrinology. . '

Visit us at: Other Publications;

educatfon.endocrine.org endocrine.org/publications
endocrine.org

The statements and opinions expressed in this publication are

those of the individual authors and do not necessarily reflect
1
the views of the Endocrine Society The Endocrine Society is not
responsible or liable in any way for the currency of the information, %
for any errors, omissions, or inaccuracies, or for any consequences
arising therefrom. With respect to any drugs mentioned, /
the reader is advised to refer to the appropriate medical
literature and the product information currently provided by the
manufacturer to verify appropriate dosage, method and duration
of administration, and other relevant information; In all instances, :
it is the responsibility of the treating physician or other health care
professional, relying on independent experience and expertise, as /

well as knowledge of the patient, to determine the best treatment %

for the patient /: /
'
•

. -V
PERMISSIONS: For permission to reuse material, please visit the
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M
Copyright Clearance Center {CCCJ at www.copyright.com or call
978-750-8400. CCC is a non-for- profit organization that provides
licenses and registration for a variety of uses.

Copyright © 2020 by the Endocrine Society, 2055 L Street NW, ,

~
Suite 600, Washington, DC 20036. All rights reserved;No part of
this publication may be reproduced, stored in a retrieval system,
posted on the Internet, or transmitted in any form, by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without written permission of the publisher, / 4

TRANSLATIONS AND LICENSING: Rights to translate and

reproduce Endocrine Society publications internationally are
extended through a licensing agreement on full or partial
editions; To request rights for a local edition, please visit:
endocnne.org/products-and- services/licensing .
ISBN: 978-1-879225-65- 7
Library of Congress Control Number; 2019954327

ti Esidocrime Board Review

1
m

OVERVIEW
The Endocrine Board Review (EBR ) is a board examination
preparation course designed both for endocrine fellows
who have completed or are nearing completion of then-
fellowship and are preparing to sit the board certification
exam, and for practicing endocrinologists in search of a
comprehensive self-assessment of endocrinology, either to
prepare for recertification or to update their practice. EBR
consists of 220 case-based, American Board oflnternal
Medicine ( ABIM ) style, multiple-choice questions, presented
in a mock exam format. Each section follows the ABIM
Endocrinology, Diabetes, and Metabolism Certification
Examination blueprint, covering the breadth and depth
of the certification and recertification examinations. Each
case is discussed comprehensively with detailed answer
explanations and references. A customized score report is
provided to those participating in the online courses.
ACCREDITATION STATEMENT
The Endocrine Society is accredited
by the Accreditation Council for
Continuing Medical Education
Pi
tACCREDITED
ACCME?
WITH
COMMENDATION
’
( ACCME ) to provide continuing medical
education for physicians. The Endocrine Society has
achieved Accreditation with Commendation.
METHODS OF PARTICIPATION
This material is presented in 3 activities, as follows:
. * Endocrine Board Review 2020: interactive online
.
program includes early access to topical on -demand
presentations and live Q&A sessions with the experts
held September 16 - 18, 2020.
Endocrine Board Review Online 2020: enduring online
activity
• « Endocrine Board Review, 12th Edition: enduring book activity
.
AMA PRA CATEGORY 1 CREDITS (CME) AND
MAINTENANCE OF CERTIFICATION (MOC )
The Endocrine Society designates
ABIM
this activity for a maximum of 21 AMA
PRA Category 1 Credits and 21 points in AzmsDirm
the ABIM's Maintenance of Certification
( MOC) program. Physicians should claim only the credit
commensurate with the extent of their participation in the
activity. Participants will earn MOC points equivalent to the
amount of CME credits claimed for the activity.
Successful completion of this CME activity includes
participation in the activity evaluation. To complete the
activity evaluation and claim CME credits and/ or MOC points,
participants must visit the Endocrine Society's Center
for Learning at education.endocrine.org . After completing
the activity evaluation, participants will be able to save or
print a CME certificate. It is the CME activity provider s
responsibility to submit participant completion information to
the ACCME for the purpose of granting ABIM MOC points.
CME credits and / or MOC points for the activities related to
this material must be claimed by the following deadlines.
• Endocrine Board Review 2020: December 31, 2022
0 To claim credits, visit education.endocrine .org / EBR2020
. ®
Endocrine Board Review Online 2020: October 31, 2022
° To claim credits, visit education.endocrine.org/
'
‘ EBR 2020Recordings
« Endocrine Board Review, 12th Edition: October 31, 2022
0 To claim credits, visit education.endocrine .org/ EBR 12Ed
For questions about content or obtaining CME credit
or MOC points, please contact the Endocrine Society at
education.endocrine.org/ contact.
LEARNING OBJECTIVES
Upon completion of this educational activity, learners
will be able to demonstrate enhanced medical knowledge
and clinical skills across all major areas of endocrinology;
apply knowledge and skills in diagnosing, managing,
and treating a wide spectrum of endocrine disorders;
and successfully complete the board examination for
certification or recertification in the subspecialty of
endocrinology, diabetes, and metabolism.
TARGET AUDIENCE
This CME activity is intended for endocrine
fellows planning for initial certification, practicing
endocrinologists preparing for an MOC assessment, or
physicians seeking an in- depth review of endocrinology.
The secondary target audience includes advanced practice
nurses and physician assistants.
STATEMENT OF INDEPENDENCE
As a provider of CME accredited by the ACCME, the
Endocrine Society has a policy of ensuring that the content
and quality of this educational activity are balanced,
independent, objective, and scientifically rigorous. The
scientific content of this activity was developed under
the supervision of the Endocrine Society's EBR faculty.
There are no commercial supporters of this activity
and no commercial entities have had influence over the
planning of this CME activity.
DISCLOSURE POLICY
The faculty, committee members, and staff who are in
position to control the content of this activity are required
to disclose to the Endocrine Society and to learners
any relevant financial relationship (s) of the individual
or spouse/partner that have occurred within the last
12 months with any commercial interest(s ) whose products
or services are related to the CME content. Financial
relationships are defined by remuneration in any amount
Wmlocrine Board Review isi
J

from the commercial interest (s) in the form of grants;
research support ; consulting fees; salary; ownership interest
(eg, stocks, stock options, or ownership interest excluding
diversified mutual funds); honoraria or other payments
for participation in speakers bureaus, advisory boards, or
boards of directors; or other financial benefits. The intent of
this disclosure is not to prevent CME planners with relevant
financial relationships from planning or delivery of content,
but rather to provide learners with information that allows
them to make their own judgments of whether these
financial relationships may have influenced the educational
activity with regard to exposition or conclusion.
The Endocrine Society has reviewed all disclosures and
resolved or managed all identified conflicts of interest, as
applicable.
The faculty reported the following relevant financial
relationship( s ) during the content development process for
this activity:
Natalie Cusano, MD, MS, has served as a consultant to
Shire / Takeda and Radius Pharmaceuticals and has served
as a speaker for Shire/ Takeda and Alexion.
Tobias Else, MD, has served as an advisory board member
to Corcept Therapeutics and HRA Pharma, and his
institution has received research support from Corcept
Therapeutics, Merck and Strongbridge Biopharma.
Serge A, Jabhour, MD, has served as a consultant to
AstraZeneca and Janssen, and his institution has received
research support from the National Institutes of Health .
Laurence Katznelson, MD, has served as a consultant and
principal investigator to Chiasma and Camarus, and he has
served as an advisory board member to Novo Nordisk .
Michelle F. Magee, MD, receives research support from the
NIH Diabetes Prevention Program Observational Study and
the NIH Grade Study as an investigator on behalf of MedStar
Health Research Institute. She serves as a speaker for the
American Diabetes Association, the American College of
Cardiology, and the Endocrine Society.
Kathryn A. Martin, MD, has served as a physician editor for
UpToDate.
The following faculty reported no relevant financial
relationships: Andrea D. Coviello , MD; Frances J. Hayes,
MB BCh, BAO; and Jacqueline Jonklaas, MD, PhD, MPH
The medical editor for this activity reported no relevant
financial relationships: Abbie L. Young, MS, CGC, ELS ( D )
Endocrine Society staff associated with the development
of content for this activity reported no relevant financial
relationships .
DISCLAIMERS
The information presented in this activity represents the
opinion of the faculty and is not necessarily the official
position of the Endocrine Society.
sv
1
1
I
Use of professiona! judgment:
The educational content in this activity relates to basic
principles of diagnosis and therapy and does not substitute \
for individual patient assessment based on the health care
provider s examination of the patient and consideration
of laboratory data and other factors unique to the patient.
Standards in medicine change as new data become available.
|
Drugs and dosages: 1
"
When prescribing medications , the physician is advised
to check the product information sheet accompanying
each drug to verify conditions of use and to identify any
changes in drug dosage schedule or contraindications.
POLICY ON UNLABELED/OFF- LABEL USE
The Endocrine Society has determined that disclosure of
unlabeled/ off -label or investigational use of commercial
product(s) is informative for audiences and therefore
requires this information to be disclosed to the learners
at the beginning of the presentation. Uses of specific
therapeutic agents, devices, and other products discussed
in this educational activity may not be the same as those
indicated in product labeling approved by the Food and Drug
Administration ( FDA). The Endocrine Society requires that
any discussions of such “off-label” use be based on scientific
research that conforms to generally accepted standards
of experimental design, data collection, and data analysis.
Before recommending or prescribing any therapeutic agent
or device, learners should review the complete prescribing
information, including indications, contraindications,
warnings, precautions, and adverse events.
PRIVACY AND CONFIDENTIALITY STATEMENT $
The Endocrine Society will record learners personal -I
information as provided on CME evaluations to allow for
issuance and tracking of CME certificates. The Endocrine
Society may also track aggregate responses to questions
in activities and evaluations and use these data to inform
the ongoing evaluation and improvement of its CME
program. No individual performance data or any other
personal information collected from evaluations will be
shared with third parties.
ACKNOWLEDGMENT OF COMMERCIAL
SUPPORT
The activity is not supported by educational grant (s ) or
other funds from any commercial supporters.
Last Review: August 2020
Activity Release: August 2020
Activity Expiration Date: ( date after which this material
is no longer certified for credit ): see section titled “ AAIA
PIT 4 Category l Credits ( CME ) and Maintenance of
Certification ( MGC) ”
 Contents
QUESTIONS ANSWERS

LABORATORY REFERENCE RANGES 1

COMMON ABBREVIATIONS USED IN

ENDOCRINE BOARD REVIEW 5

ADRENAL BOARD REVIEW 7 93

Tobias Else, MD

CALCIUM & BONE BOARD REVIEW 18 111

Natalie Cusano, MD, MS

DIABETES MELLITUS SECTION 1BOARD REVIEW 29 130

Serge A. Jabbour, MD

DIABETES MELLITUS SECTION 2 BOARD REVIEW 40 149

Michelle F. Magee, MD

FEMALE REPRODUCTION BOARD REVIEW 53 172

Kathryn A. Martin, MD

MALE REPRODUCTION BOARD REVIEW 59 182

Frances J. Hayes, MB BCh, BAO

OBESITY & LIPIDS BOARD REVIEW 66 196

Andrea D. Coviello, MD

PITUITARY BOARD REVIEW 74 218

Laurence Katznelson, MD

THYROID BOARD REVIEW 81 231

Jacqueline Jonklaas, MD, PhD , MPH

For mid volume updates to this book's content, go to endocrine.org/ bookupdates.

-

Ettdserme Ecsttrd Review v

I®
 LABORATORY REFERENCE RANGES
Reference ranges vary among laboratories. Conventional units are listed first with SI units in parentheses.

Lipid Values Thyroid Values

High- density lipoprotein (HDL) cholesterol Thyroglobulin 3 - 42 ng/mL (3 - 42 pg/L) (after surgery and
Optimal >60 mg/dL (>1.55 mmol/L) radioactive iodine treatment: < 1.0 ng/mL [<1.0 pg/L] )
Normal - 40 - 60 mg/dL (1,04- 1.55 mmol/L) Thyroglobulin antibodies —— - <4.0 lU/mL (<4.0 klU/L)
Low — < 40 mg/dL (<1.04 mmol/L) Thyrotropin (T$H ) - —- 0.5 - 5.0 mlU/L
Low - density lipoprotein (LDL) cholesterol Thyrotropin-receptor antibodies ( TRAb) <1.75 IU/ L

Optimal <100 mg/dL (< 2.59 mmol/L) Thyroid -stimulating immunoglobulin — <120% of basal activity
Low — -100- 129 mg/dL (2.59-3.34 mmol/L) Thyroperoxidase ( TPO) antibodies - < 2.0 JU/mL (<2.0 klU/L)
Borderline -high - -130- 159 mg/dL (3.37-4.12 mmol/L) Thyroxine ( TJ (free) — 0.8-1.8 ng/dL (10.30 - 23.17 pmol/L)
High - -160- 189 mg/dL ( 4.14-4.90 mmol/L) Thyroxine ( TJ (total) 5.5-12.5 pg/dL (94.02 - 213.68 nmol/L)
Very high — >190 mg/dL (>4.92 mmol/L) Free thyroxine ( TJ index — 4-12
Non- HDL cholesterol Triiodothyronine ( TJ (free) - 2.3 - 4.2 pg/mL ( 3.53 - 6.45 pmol/L)
Optimal - <130 mg/dL (<3.37 mmol/L) Triiodothyronine ( TJ (total) 70- 200 ng/dL (1.08-3.08 nmol/L)
Borderiine -high - 130- 159 mg/dL (3.37 - 4.12 mmol/L) Triiodothyronine ( TJ, reverse - - 10 - 24 ng/dL (0.15-0.37 nmol/L)
High - > 240 mg/dL (>6.22 mmol/L) Triiodothyronine uptake , resin 25%- 38%
Total cholesterol Radioactive iodine uptake — 3 %-16% {6 hours):
Optimal <200 mg/dL (<5.18 mmol/L) 15% - 30% (24 hours)
Borderline -high - • 200- 239 mg/dL ( 5.18 - 6.19 mmol/L)
High > 240 mg/dL (>6.22 mmol/L) Endocrine Values
Triglycerides Serum
Optimal <150 mg/dL (<1.70 mmol/L) Aldosterone - 4 - 21 ng/dL (111.0- 582.5 pmol/L)
Borderline -high - - 150 -199 mg/dL {1.70 - 2.25 mmol/L) Alkaline phosphatase — — 50-120 U/L (0.84- 2.00 pkat /L)
High 200 - 499 mg/dL ( 2.26 - 5.64 mmol/L) Alkaline phosphatase (bone -specific)
Very high > 500 mg/dL (>5.65 mmol/L) < 20 pg/L (adult male): <14 pg/L (premenopausal female);

Lipoprotein (a ) <30 mg/dL {<1.07 pmol/L) < 22 pg/L (postmenopausal female)

Apolipoprotein B — 50-110 mg/dL (0.5 - 1.1 g/L) Androstenedione
65 - 210 ng/dL ( 2.27 - 7.33 nmol/L) (adult male) ;
Hematologic Values 30 - 200 ng/dL (1.05- 6.98 nmol/L) (adult female)
Erythrocyte sedimentation rate 0- 20 mm/h Antimullerian hormone
Haptoglobin 30 - 200 mg/dL (300 - 2000 mg/L ) 0.7 - 19.0 ng/mL (5.0-135.7 pmol/L) (male, > 12 years);
Hematocrit- - 41% - 50 % (0.41- 0.51) (male) ; 0.9 -9.5 ng/mL (6.4-67.9 pmol/L) (female, 13 - 45 years) ;
35% - 45% (0.35 0.45) (female)
-
<1.0 ng/mL (< 7.1 pmol/L) (female, >45 years)
Hemoglobin Alc 4.0 o/o- 5.6% ( 20 -38 mmol/mol) Calcitonin <16 pg/mL (<4.67 pmol/L) (basal, male);
Hemoglobin — 13.8 - 17.2 g/dL (138-172 g/L) (male); <8 pg/mL (< 2.34 pmol/L) ( basal, female);
12.1-15.1 g/dL (121- 151 g/L) (female) <130 pg/mL (<37.96 pmoi/L) ( peak calcium infusion, male);
International normalized ratio - 0.8 - 1.2 <90 pg/mL (<26.28 pmol/L) (peak calcium infusion, female)

. Mean corouscular volume (MCV) ~ 3

Platelet count
Protein (total)
Reticulocyte count
White blood cell count
80-100 pm (80 - 100 fL) Carcinoembryonic antigen < 2.5 ng/mL (<2.5 pg/L)
150- 450 x 103/pL ( 150 - 450 x 109/L) Chromogranin A < 93 ng/mL (<93 pg/L)
6.3 -7.9 g/dL (63 - 79 g/L) Corticosterone --- 53 - 1560 ng/dL (1.53 - 45.08 nmol/L) (>18 years)
0.5%- 1.5% of red blood cells (0.005 - 0.015) Corticotropin (ACTH) -10 -60 pg/mL ( 2.2 - 13.2 pmo!/L)
4500 -11,000/pL ( 4.5 - 11.0 x 109/L) Cortisol (8 AM) —- 5 - 25 pg/dL (137.9 - 689.7 nmol/L)

Board Review 1
as
1

Cortisol ( 4 PM) - 2- 14 pg/dL (55.2-386.2 nmol/L) 17- Hydroxypregnenolone 29-1S9 ng/dL (0.87 - 5.69 nmol/L)
C - peptide —- — '
0.9 - 43 ng/mL (0.30- 1.42 nmol/L) l7 a -Hydroxyprogesterone
C-reactive protein — - - -—
. r- r
' '
r . 0.8 - 3.1 mg/L (7.62- 29.52 nmol/L) < 220 ng/dL (<6.67 nmol/L) ( adult male);
Cross-linked N-teiopeptide of type 1collagen <80 ng/dL (< 2.42 nmol/L) (follicular, female) ;
5.4-24.2 nmol BCE/mmol creat (male); <285 ng/dL (<8.64 nmol/L) ( luteal, female); '

:
6.2 - 19.0 nmol BCE/mmol creat (female) <51.ng/dL (1.55 nmol/L) (postmenopausal, female)
Dehydroepiandrosterone sulfate (DHEA -S) 25 - Hydroxyvitamin D
< 20 ng/mL (<49.9 nmol/L) (deficiency) ;
Patient Age Female Male
21- 29 ng/mL ( 52.4- 72.4 nmoi/L) (insufficiency) ;
18 - 29 years 44-332 pg/dL 89- 457 pg/dL 30-80 ng/mL (74.9-199.7 nmol/L) (optimal levels);
(1.19 - 9.00 pmol/L) ( 2.41- 12.38 pmol/L)
>80 ng/mL (>199.7 nmol/L) (toxicity possible)
30- 39 years 31- 228 pg/dL 65 - 334 pg/dL Inhibin B 15 - 300 pg/mL ( 15- 300 ng/L)
(0.84 -6.78 pmol/L) ( 1.76- 9.05 pmol/L)
Insulinlike growth factor 1 (IGF-1)
40 - 49 years 18- 244 pg/dL 48 - 244 pg/dL
(0.49 - 6.61 pmol/L) (1.30 - 6.61 pmol/L) Patient Age Female Male m
50 - 59 years 15 - 200 pg/dL 35 - 179 pg/dL 18 years 162 - 541 ng/mL 170 - 640 ng/mL
(0.41- 5.42 pmol/L) (0.95- 4.85 pmol/L) :3
( 21.2 - 70.9 nmol/L) ( 223 - 83.8 nmol/L)

>60 years 15 -157 pg/dL 25-131 pg/dL 19 years 138 - 442 ng/mL 147 - 527 ng/mL
(0.41- 4.25 pmol/L) (0.68 - 3.55 pmoi/L) (18.1- 57.9 nmol/L) (193 - 69.0 nmol/L)

20 years 122- 384 ng/mL 132 - 457 ng/mL

(16.0- 503 nmol/L) (173 - 59.9 nmol/L)
Deoxycorticosterone <10 ng/dL (<030 nmol/L) (>18 years)
1,25- Dihydroxyvita min D 3 - — 16- 65 pg/mL ( 41.6-169.0 pmol/L) 21- 25 years 116 - 341 ng/mL 116- 341 ng/mL
(15.2 - 44.7 nmol/L) (15.2- 44.7 nmol/L)
Estradiol 10 - 40 pg/mL (36.7 - 146.8 pmol/L) ( male) ;
10-180 pg/mL (36.7 - 660.8 pmol/L) (follicular, female) ; 26- 30 years 117 - 321 ng/mL 117 - 321 ng/mL
(153 - 42.1 nmol/L) ( 15.3 - 42.1 nmol/L)
100 - 300 pg/mL (367.1- 1101.3 pmol/L) (midcycle, female) ;
40- 200 pg/mL (146.8 - 734.2 pmol/L) (luteal, female); 31- 35 years 113- 297 ng/mL 113- 297 ng/mL
(14.8 - 38.9 nmol/L) (14.8- 38.9 nmol/L)
< 20 pg/mL (<73.4 pmol/L) (postmenopausal, female)
Estrone 10 - 60 pg/mL (37.0 - 221.9 pmol/L) (male); 36 - 40 years 106- 277 ng/mL 106 - 277 ng/mL
( 13.9- 36.3 nmol/L) ( 13.9 - 36.3 nmol/L)
17 - 200 pg/mL (62.9 - 739.6 pmol/L) (premenopausal female);
7 - 40 pg/mL ( 25.9- 147.9 pmol/L) (postmenopausal female) 41- 45 years 98 - 261 ng/mL 98 - 261 ng/mL
(12.8 - 34.2 nmol/L) (12.8- 34.2 nmol/L)
a-Fetoprotein <6 ng/mL (<6 pg/L)
Follicle- stimulating hormone (FSH) — 46- 50 years 91- 246 ng/mL 91- 246 ng/mL
(11.9 - 32,2 nmol/L) ( 11.9 - 32.2 nmol/L)
1.0 - 13.0 mlU/mL (1.0- 13.0 IU/L) (male) ;
<3.0 miU/mL (<3.0 IU/L) (prepuberty, female) ; 51- 55 years 84 - 233 ng/mL 84- 233 ng/mL
( 11.0 - 30.5 nmol/L) (11.0 -30.5 nmol/L)
2.0- 12.0 mlU/mL ( 2.0 - 12.0 IU/L) (follicular, female) ;
4.0 - 36.0 mlU/mL ( 4.0- 36.0 IU/L) (midcycle, female); 56 - 60 years 78 - 220 ng/mL 78 - 220 ng/mL 1

(10.2 - 28.8 nmol/L) (10.2- 28.8 nmol/L)

1.0 - 9.0 mlU/mL (1.0 -9.0 IU/L) (luteal, female) ;
>30.0 mlU/mL (>30.0 IU/ L } (postmenopausal, female) 61- 65 years 72- 207 ng/mL 72 - 207 ng/mL
(9.4- 27.1 nmol/L) (9.4- 27.1 nmol/L)
Free fatty acids 10.6 - 18.0 mg/dL ( 0.4 - 0.7 nmol/L)
Gastrin <100 pg/mL ( <100 ng/L) 66 - 70 years -
67 195 ng/mL 67 -195 ng/mL
(8.8 - 25.5 nmol/L) (8.8- 25.5 nmol/L)
Growth hormone (GH) — 0.01- 0.97 ng/mL (0.01- 0.97 pg/L) ( male);
0.01-3.61 ng/mL (0.01- 3.61 pg/L) (female) 71- 75 years -
62 184 ng/mL 62-184 ng/mL
(8.1- 24.1 nmol/L) (8.1- 24.1 nmol/L)
Homocysteine <1.76 mg/L ( <13 pmol/L)
p-Human chorionic gonadotropin (p- hCG) — — 76 - 80 years -
57 172 ng/mL 57 -172 ng/mL
(7.5 - 22.5 nmol/L) ( 7.5 - 22.5 nmol/L)
<3.0 miU/mL (<3.0 IU/L) (nonpregnant female) ;
> 25 mlU/mL (> 25 IU/ L) indicates a positive pregnancy test >80 years 53 - 162 ng/mL 53 -162 ng/mL
(6.9 - 21.2 nmol/L) ( 6.9 - 21.2 nmol/L)
p-Hydroxybutyrate <3.0 mg/dL (<288.2 pmol/L)
aj
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irt iiiti' trfT
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 Insuiinlike growth factor binding protein 3 2.5 - 4.8 mg/L Renin activity, plasma, sodium replete, ambulatory

Insulin - '
1.4 14.0 plU/mL (9.7 97.2 pmol/L)
- - 0.6 - 4.3 ng/mL per h

islet- cell antibody assay — Renin, direct concentration 4- 44 pg/mL (0.1- 1.0 pmol/L)

0 Juvenile Diabetes Foundation units Sex hormone-binding globulin ( SH8 G)

ITT i Luteinizing hormone (LH) — - 1.1- 6.7 pg/mL { 10-60 nmol/L) (male);
T..L: J
yy 1.0 - 9.0 mlU/mL ( 1.0 - 9.0 IU/L) (male) ; 2.2- 14.6 pg/mL ( 20 -130 nmol/L) (female)
;'

f: <1.0 mlU/mL {<1.0 IU/L ) (prepuberty, female) ; a-Subunit of pituitary glycoprotein hormones
4
— —
1.0 - 18.0 mlU/mL ( 1.0 18.0 IU/L) (follicular, female) ;
-
<1.2 ng/mL {<1.2 pg/L)
20.0 - 80.0 mlU/mL ( 20.0 80.0 IU/L) (midcycle , female) ;
-
Testosterone ( bioavailable) -
0.5 - 18.0 mlU/mL (0.5 - 18.0 IU/L) (luteal, female); 0.8 - 4.0 ng/dL (0.03 -0.14 nmol/L)
fT ":
>30.0 mlU/mL (> 30.0 IU/L) (postmenopausal, femcle) ( 20- 50 years, female on oral estrogen) ;

Metanephrines ( plasma fractionated) 0.8 - 10.0 ng/dL (0.03 - 0.35 nmol/L)

Metanephrine — - <99 pg/mL (<0.50 nmol/L) ( 20 - 50 years, female not on oral estrogen);
LTV
Normetanephrine <165 pg/mL (<0.90 nmol/L) 83.0- 257.0 ng/dL ( 2.88-8.92 nmol/L) (male 20- 29 years ) ;
75 g oral glucose tolerance test blood glucose values -
* 72.0 - 235.0 ng/dL ( 2.50-8.15 nmo!/L) (male 30-39 years) ;
60 - 100 mg/dL (3.3 - 5.6 mmol/L) ( fasting) ; 61.0- 213.0 ng/dL ( 2.12- 7.39 nmol/L) (male 40 - 49 years);

& - .. <200 mg/dL {< 11.1 mmoi/L) (1 hour) ; 50.0 - 190.0 ng/dL (1.74- 6.59 nmo!/L) (male 50 - 59 years);
.
tev -r:
K
<140 mg/dL {<7.8 mmol/L) ( 2 hour); 40.0 - 168.0 ng/dL (1.39- 5.83 nmol/L) (male 60 -69 years)
between 140 - 200 mg/dL ( 7.8 - 11.1 mmol/L) is considered Testosterone (free) 9.0 - 30.0 ng/dL (0.31- 1.04 nmol/L) (male) ;
impaired glucose tolerance or prediaoetes. Greater than 0.3 - 1.9 ng/dL (0.01- 0.07 nmol/L) (female)
200 mg/dL ( 11.1 mmol/L) is a sign of diabetes meilitus. Testosterone (total) 300 - 900 ng/dL (10.4- 31.2 nmol/L) (male) ;
50 - g oral glucose tolerance test for gestational diabetes 8-60 ng/dL (0.3 - 2.1 nmol/L) (female)
<140 mg/dL (<7.S mmol/L) (1 hour ) Vitamin B 12 180-914 pg/mL ( 133 - 674 pmol/L)
100- g orcl glucose tolerance test for gestational diaoetes
<95 mg/dL {< 5.3 mmol/L) (fasting ); Chemistry Values
Sfc - < 180 mg/cL ( <10.0 mmol/L) (1 hour ); Alanine aminotransferase — -10- 40 U/L (0.17 - 0.67 pkat/L)
: V\
- • | < 155 mg/dL ( <8.6 mmol/L) ( 2 hour) ; Albumin 3,5 - 5 ,0 g/dL (35 - 50 g/L)

m
c.:;
- <140 mg/dL ( < 7.8 mmoi/L) (3 hour ) Amylase - - 26-102 U/L (0.43 - 1.70 pkat/L)

§.& - Osteocalcin 9.0 - 42.0 ng/mL (9.0 - 42.0 pg/L) Aspartate aminotransferase - — - 20 48 U/L (0.33 -0.80 pkat/L)
-

iT , Parathyroid hormone, intact (PTH) 10 - 65 pg/mL (10-65 ng/L) Bicarbonate — 21- 28 mEq/L ( 21- 28 mmol/L)
NS Parathyroid hormone-related protein (PTHrP) <2.0 pmol/L Bilirubin (total) -0.3 - 1.2 mg/dL ( 5.1- 20.5 pmol/L)
m Progesterone <1.2 ng/mL (<3.8 nmol/L) (male); Blood gases
85 - <1.0 ng/mL (<3.2 nmol/L) ( follicular, female) ; Po2, arterial blood • 80 -100 mm Hg (10.6 - 13.3 kPa )
2.0 - 20.0 ng/mL (6.4 - 63.6 nmol/L) (luteal, female); Pco 2, arterial blood - — 35 - 45 mm Hg (4.7 - 6.0 kPa)
ft: <1.1 ng/mL (<3.5 nmol/L) (postmenopausal, female) ; Blood pH 7.35- 7.45

i > 10.0 ng/mL (>31.8 nmol/L) (evidence of ovulatory adequacy)

Prcinsulin - 26.5-176.4 pg/mL (3.0- 20.0 pmol/L)
Calcium
Calcium (ionized)
8.2 - 10.2 mg/dL (2.1- 2.6 mmol/L)
4.60 - 5.08 mg/dL (1.2 - 1.3 mmol/L)
Prolactin - 4- 23 ng/mL (0.17 - 1.00 nmol/L) ( male); Carbon dioxide 22- 28 mEq/L (22- 28 mmol/L}
4 30 ng/mL (0.17 - 1.30 nmol/L) (nonlcctating female) ;
-
CD 4 ceil count - - 500 - 1400/pL (0.5-1,4 x 109/L}
y J
s#:
,

10 - 200 ng/mL ( 0.43 - 8.70 nmol/L ) (lactcting female) Chloride 96 - 106 mEq/L (96 - 106 mmol/L)
y
; Prostate - specific antigen (PSA ) Creatine kinase - 50 - 200 U/L (0.84- 3.34 pkat /L)
'

< 2.0 ng/mL (< 2.0 pg/L ) (<40 years) ; Creatinine 0.7- 1.3 mg/dL (61.9 - 114.9 pmol/L) (male);
y < 2.8 ng/mL (< 2.8 pg/L) { <50 years); 0.6 - 1.1 mg/dL ( 53.0 - 97.2 pmol/L) (female)
.. .

< 3.8 ng/mL {< 3.8 pg/L) (<60 years); Ferritin 15 - 200 ng/mL (33.7 - 449.4 pmol/L)
HP 1 <5.3 ng/mL { <5.3 pg/L) { <70 years); Folate >4.0 ng/mL (>4.0 pg/L)
yyfy
#y
<7.0 ng/mL (< 7.0 pg/L) { <79 years); Glucose — - 70 - 99 mg/dL (3.9 - 5.5 mmol/L)
yr <7.2 ng/mL (< 7.2 pg/L) (>80 years ) y- Gluta my [ transferase 2 - 30 U/L (0.03 -0.50 pkat /L)

s$ j
IT?" : UmU>ejm& Bosird Review 3
i :
 I

Iron Citrate 320 -1240 mg/24 h (16.7 - 64.5 mmol/d)

50 - 150 |jg/dL (9.0 - 26.8 pmol/L) (male) ; Cortisol - 4- 50 pg/24 h (11-138 nmol/d)
35 -145 |jg/dL (6.3 - 26.0 pmoi/L) (female) Cortisol following dexamethasone suppression test
Lactate dehydrogenase 100 - 200 U/L ( 1.7 - 3.3 pkat/L) (low - dose: 2 day, 2- mg daily ) 10 pg/ 24 h (<27.6 nmol/d )
Lactic acid - - 5.4- 20.7 mg/dL (0.6 - 2.3 mmol/L) Creatinine - 1.0 - 2.0 g/ 24 h (8.8- 17.7 mmol/d )
Lipase — 10- 73 U/L (0.17 - 1.22 pkat /L) Glomerular filtration rate (estimated) >60 mL/min per 1.73 m 2
Magnesium 1.5 - 2.3 mg/dL (0.6 -0.9 mmol/L) 5 ^Hydroxyindole acetic acid 2 - 9 mg/24 h ( 10.5 - 47.1 pmol/d)
Osmolality 275 - 295 mOsm/kg ( 275- 295 mmol/kg) Iodine (random) >100 pjg /L
Phosphate 2.3 - 4.7 mg/dL (0.7 - 1.5 mmol/L) 17 -Ketosteroids 6.0 - 21.0 mg/ 24 h ( 20.8 - 72.9 pmol/d) (male);
Potassium 3.5 - 5.0 mEq/L (3.5- 5.0 mmol/L) 4.0 - 17.0 mg/24 h ( 13.9 - 59.0 pmol/d) (female)
Prothrombin time 8.3 - 10.8 s Metanephrine fractionation
!

Serum urea nitrogen - 8- 23 mg/dL ( 2.9 - 8.2 mmol/L) Normotensive normal ranges:
Sodium 136 - 142 mEq/L (136 - 142 mmol/L) Metanephrine <261 pg/24 h (<1323 nmol/d) (male); i
Transferrin saturation 14% - 50% <180 pg/24 h (<913 nmol/d) (female)
Troponin I <0.6 ng/mL (< 0.6 pg/L) Normetanephrine — age and sex dependent
Tryptase <11.5 ng/mL (<11.5 pg/L) Total metanephrine - age and sex dependent
Uric acid - 3,5 - 7.0 mg/dL ( 208.2 - 416.4 pmol/L) Osmolality 150 -1150 mOsm/kg (150-1150 mmol/kg) 1
Oxalate <40 mg/24 h (<456 mmol/d)
Phosphate - 0.9 - 1.3 g/ 24 h ( 29.1- 42.0 mmol/d) I
Albumin 30-300 pg/mg creat (3.4- 33.9 pg/mol creat ) Potassium 17 - 77 mEq/24 h ( 17 - 77 mmol/d)
!
Albumin -to - creatinine ratio <30 mg/g creat Sodium 40- 217 mEq/ 24 h ( 40 - 217 mmol/d )
Aldosterone 3 - 20 pg/ 24 h (8.3 - 55.4 nmol/d) Uric acid <800 mg/24 h (<4.7 mmol/d )
( should be <12 pg/ 24 h [<33.2 nmol/d] with oral sodium
loading—confirmed with 24- hour urinary sodium >200 mEq)
Calcium - 100 - 300 mg/ 24 h ( 2.5- 7.5 mmol/d) Cortisol (salivary) , midnight <0.13 pg/dL (< 3.6 nmol/L)
Catecholamine fractionation
Normotensive normal ranges: Semen
Dopamine <400 pg/24 h (<2610 nmol/d) Semen analysis > 20 million sperm/mL; >50% motility
Epinephrine — <21 pg/24 h (<115 nmol/d)
Norepinephrine — <80 pg/24 h (< 473 nmoi/d)
*

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fedocnM Boarcf Review

:
 COMMON ABBREVIATIONS USED IN ENDOCRINE BOARD REVIEW
ACTH - corticotropin
ACE inhibitor = angiotensin -converting enzyme inhibitor
ALT = alanine aminotransferase
AST = aspartate aminotransferase
B3VII = body mass index
CNS = central nervous system
CT - computed tomography
DHEA = dehydroepiandrosterone
DHEA-S - dehydroepiandrosterone sulfate
DNA = deoxyribonucleic acid
DPP-4 inhibitor = dipeptidyl-peptidase 4 inhibitor
DXA = dual- energy x- ray absorptiometry
FDA = Food and Drug Administration
FGF- 23 = fibroblast growth factor 23
FNA = fme-needle aspiration
FSH = follicle-stimulating hormone
GH - growth hormone
GHRH - growth hormone-releasing hormone
GLP-1 receptor agonist = glucagonlike peptide 1 receptor
V agonist
GnRH - gonadotropin - releasing hormone
hCG = human chorionic gonadotropin
HDL = high- density lipoprotein
HIV = human immunodeficiency virus
HMG-CoA reductase inhibitor = 3-hydroxy- 3-methylglutaryl
. coenzyme A reductase inhibitor
IGF-1 - insulinlike growth factor 1
LDL = low- density lipoprotein
LH - luteinizing hormone
MCV - mean corpuscular volume
MIBG - mrta-iodobenzylguanidine
MRI = magnetic resonance imaging
NPH insulin - neutral protamine Hagedorn insulin
PCSK 9 inhibitor = proprotein convertase subtilisin /kexin 9
inhibitor
PET = positron emission tomography
PSA = prostate-specific antigen
PTH = parathyroid hormone
PTHrP ~ parathyroid hormone-related protein
SGLT- 2 inhibitor = sodium-glucose cotransporter 2 inhibitor
SHBG = sex hormone-binding globulin
T3 = triiodothyronine
T4 = thyroxine
TPO antibodies - thyroperoxidase antibodies
-
TRH = thyrotropin releasing hormone
TRAb = thyrotropin -receptor antibodies
TSH = thyrotropin
VLDL = very low- density lipoprotein
E & docrme Bomd Review 5
ENDOCRINE
BOARD
REVIEW

.
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v:
 Adrenal Board Review
Tobias Else, MD

An endocrine surgery colleague requests a

1 consult to evaluate a 38-year-old woman
who was referred to him for surgery to remove
a possible pheochromocytoma. She has episodic I
5
hypertension with blood pressure values ranging
up to 210/ 110 mm Hg accompanied by headaches, *
s
nausea, lightheadedness, and diaphoresis. These 1
:

episodes started in her early 20s, occur several times

m

per week , and last from hours to days.

She has a PhD degree in engineering and
works as an executive for a local company. She
brings a detailed log listing up to 20 blood pressure
measurements per day. Her family history is
negative for paraganglioma , pheochromocytoma ,
or cancers. At todays visit , her blood pressure is
:
Sfffr 132 / 81 mm Hg and pulse rate is 78 beats/ min .
The laboratory workup and imaging that her
primary care physician ordered are available for
:T ;
review. The CT shows a thickened left adrenal
gland with a probable central 1 -cm nodule ( see
images, arrows).
I
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Laboratory test results:
Plasma normetanephrine = 205.1 pg/ mL
( <164.8 pg/ mL) (SI: 1.12 nmol/ L [ <0.90 nmol/ L] )
Plasma metanephrine = 39.4 pg / mL ( < 98.6 pg/ mL )
( SI: 0.20 nmol / L [ < 0.50 nmol / L ] )
Sodium = 140 mEq/ L (136-142 mEq / L)
(SI: 140 mmol/ L [ 136 -142 mmol / Lj )
Potassium = 4.2 mEq / L ( 3.5-5.0 mEq / L )
(SI: 4.2 mmol/ L [ 3.5- 5.0 mmol/ L] )
Serum aldosterone = 6 ng / dL ( 4- 21 ng / dL)
(SI: 166.4 pmol / L [ 111.0-582 , 5 pmol/ L ] )
Plasma renin activity = < 0.6 ng / mL per h
( 0.6- 4.3 ng / mL per h )

Which of the following is the best next step in this

patient's care?
The 123I - MIBG -SPECT /CT shows avidity of the A. Obtain a 24 -hour urine collection for
left adrenal gland , presence of a cardiac silhouette, metanephrine and normetanephrine
and no other MIBG-avid lesion ( see image ) . B. Perform a 68Ga-DOTATATE PET -CT
C. Discuss the diagnosis of
pseudopheochromocytoma
D. Proceed with left adrenalectomy
E. Perform MRI with in - phase/ out-of- phase
imaging

Adrenal Board Review - QUESTIOMS 7

 I

A 55-year-old. man is referred for endocrine Which of the following is the best next step in this
Am consultation after a recent emergency patient's evaluation?
department visit for hypertensive urgency. He has A. 24 -Hour urine collection for cortisol
a 20-year history of hypertension controlled measurement
with hydrochlorothiazide. However, he has B. Sleep study
recently been experiencing headaches and has C. 68
Ga - DOTATATE PET- CT
measured his blood pressure more often. These D. 123
I - MIBG SPECT- CT i
measurements document values ranging between E. Repeated measurement of plasma metanephrine
160 and 190 mm Hg systolic and between 95 and levels after holding doxazosin
y8

110 mm Hg diastolic. His primary care physician j

intensified his antihypertensive regimen to include
amlodipine, losartan, and doxazosin.
He describes worsening headaches, loss of
libido, tiredness, and fatigue over the last few
months. He has gained more than 40 lb ( > 18.1 kg )
over the last 5 years, and his current BM1 is
37 kg / m 2.
On physical examination, he is a well-
developed, obese patient with typical fat
distribution and no striae, bruising, or skin
atrophy. His blood pressure is 142 /92 mm Hg.
Laboratory test results after the emergency
department visit:
Urinary metanephrine = 66 pg / 24 h ( < 261 pg / 24 h)
Urinary normetanephrine = 920 pg / 24 h
( < 484 pg / 24 h )
Plasma metanephrine = 39.4 pg/ mL ( < 98.6 pg / mL )
(SI: 0.2 nmol / L [ <0.50 nmol / L] )
Plasma normetanephrine = 183.2 pg/ mL
:#
;f A general surgeon requests a consult to
mS evaluate a 68-year- old woman for adrenal
insufficiency. The patient had a left hemicolectomy
for colon cancer with construction of a transient |
colostomy the night before. Overnight she had I
episodes of hypotension with blood pressure as
low as 90/ 50 mm Hg ( baseline blood pressure I
is 130 / 80 mm Hg) , mild fever, tachycardia of
110 beats/ min, and increased output through her
colostomy. She was treated with intravenous
fluids and 50 mg of tramadol. She developed mild
hyponati’emia, and a morning cortisol concentration
was documented to be 0.9 pg / dL ( 24.8 nmol/ L).
She does not smoke cigarettes and was healthy I
before her surgery. She has a diagnosis of mild %
hypertension and diet-controlled diabetes (most
recent hemoglobin Alc = 6.8 % [51 mmol/ mol] ) . 1
i
She is resting comfortably and does not have M
any nausea. She would like to eat. On physical
m
examination, she is obese ( BMI = 32 kg / m 2)
S//A

( < 164.8 pg / mL ) (SI: 1.0 nmol / L [ < 0 90 nmol/ L ] )

, and does not appear ill. Her blood pressure is !
. "vS
Sodium = 140 mEq / L ( 136-142 mEq/ L ) 124/ 85 mm Pig, and pulse rate is 90 beats/ min. m
(SI: 140 mmol/ L [ 136 - 142 mmol / L] ) 3
Potassium = 3.5 mEq / L ( 3.5-5.0 mEq/ L ) Her most recent basic metabolic profile shows the V

(SI: 3.5 mmol / L [3.5 - 5.0 mmol/ Lj ) following results: mm

Serum aldosterone = 18 ng/ dL ( 4- 21 ng / dL ) Sodium = 133 mEq/ L ( 136-142 mEq/ L ) m
(SI: 499.3 pmol/ L [ 111 0-582.5 pmol / L] )
, (SI: 133 mmol/ L [ 136 - 142 mmol/ L] ) I
Plasma renin activity = 1.0 ng/ mL per h Potassium = 3.8 mEq / L ( 3.5-5.0 mEq/ L) ml
(0.6-4.3 ng/ mL per h ) (SI: 3.8 mmol/ L [ 3.5-5.0 mmol/ L ] ) 1
I
Serum testosterone = 240 ng/ dL ( 300- 900 ng / dL ) Glucose = 168 mg / dL (70 -99 mg / dL ) 1
m
(SI: 8.3 nmol/ L [ 10.4 - 31.2 nmol/ L] ) (SI: 9.3 mmol/ L [ 3.9- 5.5 mmol/ L ] )
Serum creatinine = 0.7 mg/ dL ( 0.6-1.1 mg / dL)
( SI: 6 L 9 pmol/ L [ 53.0- 97.2 pmol / L ] )
t
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8 Emfocrlrie Board Review

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me of the following is the most likely cause for the On physical examination; the patient appears
Sift Which
cortisol level? chronically ill and thin . His blood pressure
'»0
low
S
ra?
''
A. Medication given as a prophylaxis for is 98 / 50 mm Hg (sitting) and 75/ 45 mm Hg
TP postoperative nausea (standing) , He can move all extremities but has

mIS '
B.
C.
Overnight use of tramadol
Primary autoimmune adrenal insufficiency
generalized weakness. Lungs are clear, and no skin
lesions are appreciated.
WOK As part of the initial workup, he had an
D. Metastasis from the colon cancer
Ofe
jjjjlsr 7
E. Delayed effect of inhaled anesthetics abdominal CT ( see image ) , which documented
bilateral adrenal masses, and a chest CT, which
A 48-year old man has recently showed no abnormalities . The following laboratory
§fe been diagnosed with adrenocortical test results were documented:
vnr
Mp# ; carcinoma. He reports no history of malignancy ; Sodium = 129 mEq /L ( 136 -142 mEq/ L )
lie but states that his brother had colon cancer at age
38 years and that his mother died of uterine cancer
(SI: 129 mmol/ L [ 136 -142 mmol/ L] )
Potassium = 5.4 mEq/ L ( 3.5-5.0 mEq/ L )
Sir at age 51 years. His mother had 5 siblings: a brother (SI: 5.4 mmol/ L [3.5-5.0 mmol/ L] )
with colon cancer in his late 50s , a sister with Serum aldosterone = < 2 ng/dL ( 4- 21 ng/ dL )
stomach cancer in her 40s , and 3 brothers who (SI: 55.5 pmol / L [111.0- 582.5 pmol/ Lj )
are alive and well in their 60s without any cancer Plasma renin activity = 64 ng/ mL per h
diagnosis. The patients maternal grandfather had (0, 6 - 4.3 ng / mL per h)
prostate cancer in his 60s and his maternal Plasma ACTH = 252 pg / mL (10- 60 pg/ mL )
grandmother had colon cancer at age 47 years. (SI: 55.4 pmol/ L [ 2.2-13.2 pmol / L] )
There are no family members with adrenal tumors. Serum cortisol ( 8 AM ) = 1.2 pg / dL ( 5 -25 pg/ dL )
The patient’s family is wondering whether they (SI: 106.1 nmol / L [ 137.9-689.7 nmol / L] )
could have a familial cancer syndrome. Serum DHEA-S = 23 pg/ dL ( 35-179 pg / dL)
(SI: 0.62 pmol/ L [0.95 - 4.85 pmol / L] )
Which hereditary syndrome is most likely in this
patient's family?
A. Li - Fraumeni syndrome
B. Lynch syndrome ( hereditary nonpolyposis colon
cancer )
age C. Familial adenomatous polyposis
gflir
UP D. Carney complex
E. Multiple endocrine neoplasia type 1
§§i
m mm;-
“•2r2 A 52-year- old man is referred for evaluation
of bilateral adrenal masses. Over the Which of the following is the most likely diagnosis
m- last 6 months, he has lost 30 lb ( 13.6 kg ) and underlying this patient's presentation?
ip developed night sweats. He has been increasingly- A. Congenital adrenal hyperplasia
isife fatigued and has had dizziness and nausea . He B. Autoimmune adrenalitis
im
It lives in a northern state and has not traveled C. Melanoma metastatic to the adrenal gland
outside the United States. He is a lifelong D. Adrenal lymphoma
nonsmoker. He has had no sick contacts and works
m
iltr in an office setting.
E. Histoplasmosis

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Aarersol Board Review - QUESTIONS
 ill
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PP; A 37-year-old woman with primary adrenal pA 32-year-old woman is referred for i
%s0 insufficiency presents for routine follow- A evaluation of an incidental adrenal mass
up . She describes worsening anorexia and nausea. that was identified on CT performed as part of
She has been on steady dosages of hydrocortisone, the workup for an episode of painless hematuria i
15 mg in the morning upon awakening and 5 mg 4 weeks ago. In taking a history, you elicit a 14-lb
in the afternoon, and fludrocortisone, 0.1 mg . (6.5-kg ) weight gain over the past year associated
daily. Adrenal insufficiency was initially diagnosed with the onset of irregular menses, hirsutism, and
at age 24 years. She follows "sick day rules” and has '
poor sleep. She takes no medications.
injectable hydrocortisone at home. She has always On physical examination, her blood pressure
been slightly hyperpigmented since diagnosis, but is 140/88 mm Hg. She has mild to moderate
she has noticed worsening hyperpigmentatioil over . facial fullness and plethora and supraclavicular fat
the last 6 months. accumulation.
Over the last year, she started the following CT demonstrates a 1.4-cm left adrenal mass
medications: combined oral contraceptives; biotin ( see image; right and left adrenal glands are identified
supplement ( for subjective hair loss); omeprazole, by arrows ) .
40 mg daily; and cholestyramine, 8 g daily ( for Right Adrenaf Left Adrenal
postcholecytectomy diarrhea ) . Diarrhea improved
slightly, but still persists. Over the course of the
last 6 weeks, she has lost 13.2 lb (6 kg) , Her current W
W
weight is 127.9 lb (58 kg ). | m
3®

On physical examination, she appears less healthy

than you remember from prior visits. She is generally A
Ml
pale and has hyperpigmentation. Her blood pressure I Wm if
is 110/ 78 mm Hg, and pulse rate is 89 beats/ min . Mmtm

Laboratory test results: Laboratory test results:

Sodium = 130 mEq / L ( 136-142 mEq/ L )
(SI: 130 mmol / L [ 136-142 mmol/ L ] )
Potassium = 5.4 mEq / L ( 3.5 - 5.0 mEq/ L )
(SI: 5.4 mmol/ L [ 3.5-5.0 mmol / L] )
Plasma renin activity = 60 ng / mL per h
(0.6- 4.3 ng / ml per h )
Plasma ACTH = 644 pg / mL (10-60 pg / mL )
(SI: pmol/ L [ 2.2-13.2 pmol/ L] )
TSH = 5.2 mlU / L (0.5-5.0 mlU/ L)
Free T 4 = 1.0 ng/ dL ( 0.8-1.8 ng / dL)
(SI: 12.9 pmol/ L [ 10.30 - 23, 17 pmol / L ] )
Sodium = 138 mEq/ L ( 136-142 mEq/ L )
(SI: 138 mmol / L [ 136 -142 mmol/ L] ) 1
i
Potassium = 3.7 mEq / L ( 3.5 - 5.0 mEq/ L)
(SI: 3.7 mmol/ L [ 3.5- 5.0 mmol / L] ) ;
1
Late-night salivary cortisol ( 2 measurements) =
0.43 pg / dL (SI: 11.9 nmol/ L)
Serum cortisol after overnight 1-mg dexamethasone
= 8.2 gg/ dL ( SI: 226.2 nmol / L)
Serum aldosterone = 4 ng / dL ( 4- 21 ng / dL)
(SI: 111.0 pmol/ L [ 111.0- 582.5 pmol/ L ] )
Pregnancy test, negative

Which of the following is the most likely cause of this Which of the following studies should be ordered next?
patient's concerns? A. Plasma renin activity
A. Cholestyramine B. Adrenal MRI
B. Omeprazole C. Dexamethasone corticotropin -
C. Hashimoto disease releasing hormone test
D . Combined oral contraceptive D . Biopsy of the adrenal tumor
E. Atrophic gastritis E. Plasma ACTH measurement

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EHi docr\n & BOQRCI Review ]

 %\
m

#% A primary care physician refers a 32 - year - g% A 59 -year -old woman is referred for a second
tl old man because of an elevated plasma »* #M opinion regarding primary aldosteronism.
« *

WjtjCTH concentration. He has a 10- year history of She developed resistant hypertension in her early
primary adrenal insufficiency due to autoimmune 50s and was found to be hypokalemic 6 months ago
adrenalitis. He also has primary hypothyroidism on routine blood testing.
due to Hashimoto thyroiditis. The patient feels
ell and has no concerns. His medications
• Screening laboratory test results:
gjinclude hydrocortisone, 12.5 mg every morning • Sodium = 142 mEq/ L ( 136 - 142 mEq / L )
jfejjd5 mg every afternoon ; fludrocortisone , 50 meg (SI: 142 mmol/ L [136- 142 mmol/ L] )
jgdaily; and levothyroxine, 125 meg daily , Potassium = 3.2 mEq / L ( 3.5-5.0 mEq / L )
til On physical examination , he is a healthy (SI: 3.2 mmol / L [ 3.5-5.0 mmol/ L] }
appearing man with a blood pressure of Serum aldosterone = 22 ng/dL ( 4- 21 ng/dL)
| 122 /76 mm Hg, a regular pulse rate of 70 beats/ min ,
f (SI: 610.3 pmoI / L [ 111.0- 582.5 pmol/ L ] )
If
and a BMI of 24 kg / m . His skin is well pigmented
2
Plasma renin activity = < 0.6 ng/ mL per h
(0.6 - 4.3 ng/ mL per h )
in sun -exposed areas . Examination findings are
otherwise normal .
On the third day of a high -salt diet, the 24-hour
Laboratory test results: urine collection documents a sodium excretion of
Electrolytes, normal
>• Vi 240 mEq/ 24 h ( 240 mmol/ d ) and an aldosterone
Nil Plasma renin activity = 2.1 ng / mL per h excretion of 24 pg / 24 h ( 66.6 nmol/ d ) . CT with
(0.6 - 4.3 ng / mL per h ) fine cuts of the adrenals shows normal glands .
HI Serum TSH = 2.8 mlU / L (0.5- 5.0 mlU / L ) She undergoes adrenal venous sampling with
: "

<
:N
Plasma ACTH = 312 pg / mL ( 10- 60 pg / mL)
T
'
continuous infusion of cosyntropin at 50 meg
m
7N
(SI: 68.6 pmol / L [ 2.2 - 13.2 pmol / L. ) per h. The results are shown ( see table ) .
She is told that the source is the left adrenal
jjjj /n addition to reviewing sick - day corticosteroid gland on the basis of the high left adrenal vein
jjjmanagement, which of the following should you aldosterone concentration and the aldosterone -to-
jjt recommend?
saga
cortisol ratio.
i§LA. Discontinue hydrocortisone and substitute
prednisone , 5 mg in the morning and 2.5 mg How should the results of the adrenal venous sampling
in the afternoon study be interpreted?
B. Add dexamethasone, 0.75 mg orally at bedtime A. Unable to localize
C. Increase the hydrocortisone dosage to 20 mg in B. Left adrenal gland is the source (left adenoma)
:
£N; - the morning and 10 mg in the afternoon
.
C. Both adrenal glands are sources ( bilateral,
ifife
i; D. Increase the fludrocortisone dosage to idiopathic hyperaldosteronism )
100 meg daily D. Insufficient information to interpret whether
|§ Make no changes in his corticosteroid
* the study was successful
dosages E. Right adrenal gland is the source ( right adenoma)
0C
is
CSrsv -
ft -

H&; Measurement Right Adrenal Vein Left Adrenal Vein inferior Vena Cava
!|
|| § fgg . .

Aldosterone 36 ng/dL 6400 ng/dL 34 ng/dL

INN: (SI: 998.6 pmol/L) (Si: 177, 536 pmol/L) (SI: 943.2 pmol/L)

. £N - Cortisol 21 pg/dL 2000 pg/dL 19 pg/dL

SI: 579.4 nmol/L} (SI: 55,176 nmoi/L) (Si: 524.2 nmol/L)
A!dosterone - to - Corti$ ol Ratio 1.7 3.2 1.8

r- 1
Adrssusi Board Review - QUESTIONS 11
h- r .
-K ,, ...
 m
•' " ;
m

t7 - -

. '

yg A 55- year-old man with rheumatoid A 71-year-old man is referred after DXA
JL arthritis has been on a stable dosage of atm %Jf documented a femoral neck T-score
fe : methotrexate and prednisone , 5 mg daily , for the of -2.9. His only other medical issue is mild
!

past 3 years. DXA performed last month shows his benign prostatic hypertrophy. He thinks he has
x-
lowest T -score to be -2.0 at the femoral neck.
:
a healthy sex drive arid has no problems achieving
.
According to the FRAX calculator, his risk for
>
or maintaining erections for intercourse. His
A major osteoporosis- related fracture is 12% and his overall strength and energy are good , and he is
risk for hip fracture is 1.1 %. His only other health still working full time. His current height is 1.5 in
issue is Barrett esophagus for which he takes long- ( 3.8 cm ) less than his peak height. On physical
h term proton -pump inhibitor therapy. examination , his BMI is 24 kg / m2. He has no
: kyphosis and there is room for 2 fingers in the
In addition to optimizing calcium and vitamin D, which space between the ribs and iliac crests in the
of the following is the best therapeutic intervention? midaxillary line.
L A. Ibandronate
B. Zoledronic acid Laboratory test results:
C. Teriparatide Complete blood cell count , normal
D. Denosumab Chemistry panel, normal
E. No intervention needed now 25- Hydroxyvitamin D = 35 ng/ mL ( 30-80 ng/ mL
[optimal] ) (SI: 87.4 nmol/ L [62.4 - 199.7 nmol/L] )
I A 74-year-old man with osteoporosis has Urinary calcium excretion - 285 mg/ 24 h
m *m 0
been on oral alendronate, 70 mg weekly, ( 100- 300 mg/ 24 h) (SI: 7.1 mmol/ d
\ for 5 years . He has no known history of fracture. [ 2.5 -7.5 mmol / d ] )
:
Current DXA shows T-scores of -2.0 at the lumbar Serum testosterone ( 8 AM ) = 285 ng / dL
spine, -2.2 at the femoral neck, and -1.6 at the ( 300- 900 ng / dL ) (SI: 9.9 nmol / L
[10.4- 31.2 nmol/ L] )
.

t; On physical examination , his height is 67 SHBG, normal

in ( 170 cm ) ( a decrease of 2.5 in [ 6.4 cm ] over
the past 4 years ) . He has moderate kyphosis
i without tenderness; gait and balance are normal
Laboratory testing documents normal levels
:
of serum calcium, phosphate, creatinine, and
’
-
LH 6.0 mlU / mL (1.0-9.0 mlU / mL)
(SI: 6.0 IU / L [ 1.0-9.0 IU / L] )
Prolactin - 6 ng /mL ( 4 - 23 ng/ mL )
(SI: 0.3 nmol / L [ 0.17 -1.00 nmol/ L ] )
PSA = 6.5 ng / mL ( < 7.0 ng / mL)

25 - hvdroxyvitamin D. Testosterone is at the lower (SI: 6.5 pg/ L [ < 7 pg / L] )

i end of normal He expresses concerns about long-
term adverse effects from bisphosphonates. Winch of the following treatments should be
recommended?
Which of the following should be the next step in this A. Testosterone gel
patient's management? B. Testosterone gel plus finasteride
A . Continue oral alendronate C. Hydrochlorothiazide
B. Discontinue alendronate but reassess D . Risedronate
:
in 1 to 2 years E. Teriparatide
C. Measure fasting serum C- telopeptide
D. Obtain lateral spine radiographs
E . Obtain radiographs of both proximal femurs

:
:

:
Ccjfofcwi & Board Review - QUESTIONS

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Another random document with
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 A Disappearing Towel

The Weight Draws the Towel into the Case Out of Sight When Not in Use

Nothing is more unsightly to a stranger entering a home than a

dirty towel in either the bathroom or the kitchenette. To keep the
towel out of sight I made a hanger as shown in the illustration. A wire
was bent into shape similar to a clothes hanger and a sliding clip
made to hold the towel in place. A cabinet was made to
accommodate the towel, and the hanger was attached to a cord run
over a pulley fastened at the top, through a weight pulley, and then
tied to a screw eye at the top. The weight draws the towel into the
cabinet. Near the bottom edge a slot was cut and a small panel fitted
in it. This small panel is fastened to the lower end of the towel. It is
only necessary to pull out the small panel to get at the towel. When
through with the towel, let loose of it and the weight will draw it into
the opening.—Contributed by Chas. C. Bradley, W. Toledo, O.
 Ammonia-Carrying Case for Insect Bites

An old clinical-thermometer case can be easily turned into a vial in

which to carry ammonia for insect bites. Fit a small rubber stopper in
the case, then push a darning needle into the stopper so that its end
will be a little more than midway in the case. Cut or break off the
needle end projecting on the outside and attach a small wad of
cotton to the inside end. The case is then filled with ammonia. For
bee stings this works fine, as the ammonia completely neutralizes
the formic acid which the bee deposits.—Contributed by E. Everett
Buchanan, Elmira, N. Y.
¶The contact points of a firm-joint caliper should never be struck on
hard surfaces to adjust them.
 How to Make Combined Kites
By C. M. MILLER

PART II—A Festooned Kite

Morekite.thanTheoneonekiteillustrated
on the same framework is known as a compound
consists of three tailless kites on one
long stick, called the spine. The upper one is 3 ft.; the center one, 2
ft., and the lower one, 1 ft. in width. There will be needed for the
construction of this kite a stick of light wood—spruce is best, but it
may be of pine or bass—7 ft. long by ¹⁄₄ by ¹⁄₂ in. If the wood breaks
easily it will be better to increase the width from ¹⁄₂ in. to ³⁄₄ in., or the
stick might be made ³⁄₈ in. thick without increasing the width, but with
a good spruce stick the dimensions first given will be sufficient. The
stick should be straight-grained and without a twist. If the spine is
twisted, the kites will not lie flat or in a plane with each other, and if
one is out of true, it will cause the kite to be unsteady in the air. The
bow sticks are three, the upper one being 4 ft. long by ¹⁄₄ by ¹⁄₂ in.;
the center one, 2 ft. long by ¹⁄₄ by ³⁄₈ in., and the lower one, 1 ft. long
by ¹⁄₄ by ¹⁄₄ in. About five sheets of tissue paper will be required, but
more may be needed for color combinations. The so-called French
tissue paper is much better, as it comes in fine colors and is much
stronger than the ordinary tissue. It costs a trifle more, but it pays in
making a beautiful kite. The Chinese rice paper is the strongest, but
it comes only in natural colors.
 The Spine with the Bow Sticks The Kite as It Appears with the
Properly Spaced as Shown by the Festoons Hung to the Ends of the
Dimensions Sticks

It will be seen that the kites do not extend to the top and bottom of
the spine stick. The first bow stick is placed 13 in. from the top end of
the spine, and each of its ends extends 6 in. beyond the kite for
fastening the festoons. The bow sticks should be lashed to the spine,
not nailed. Wind diagonally around the two sticks, both left and right,
then wind between the two, around the other windings. This draws
all windings up tightly to prevent slipping.
To string up the upper kite, drill a small hole through the spine, 6
in. from the top, at A, and also 6 in. from each end of the bow stick,
at B and C. If a small drill is not available, notch the stick with a knife
or saw to hold the string. Another hole is made in the spine 29 in.
from the upper bow stick, or at D. Tie the outline string at A, then
pass through the hole at C, then through D, up through B and back
to the starting point at A. In tying the last point, draw up the string
tightly, but not enough to spring the spine or bow. Measure carefully
to see if the distance AC is the same as AB, and if CD is equal to
BD. If they are not, shift the string until they are equal and wind at all
points, as shown at E, to prevent further slipping. Proceed in the
same way with the center and lower kite, and it will be ready for the
cover.
The cover tissue should be cut about 1 in. larger all around than
the surface to be covered, but turn over about half of this allowance.
This will give plenty of looseness to the cover. For the fringe
festoons, cut strips of tissue paper, 2¹⁄₂ in. wide, paste ¹⁄₂ in. of one
long edge over a string, and cut slits with scissors at intervals of 1 in.
along the loose edge. After the fringe has been made, attach it as
shown in the illustration. Do not stretch it tightly, but give sufficient
looseness to make each length form a graceful curve and keep the
sides well balanced.
To bend the bows of the upper and center kites, attach a string
from end to end of each bow on the back side of the kite and spring
in short brace sticks in the manner usual for tailless kites.
Attach the upper end of the bridle at A. The length of the bridle
string is 87 in. and the kite line is attached to it 30 in. from A, leaving
the lower part from this point to F, where it is tied to the spine, 57 in.
long.
The kite should fly without a tail, but if it dodges too much, attach
extra streamers to the ends of the bow sticks of the lower kite, and to
the bottom of the spine.
If good combinations of colors are used a very beautiful kite will be
the result, and one that will fly well.
 Simple Experiment in Electromagnetism

A Small Coil of Wire Mounted on a Cork Floating in Dilute

Sulphuric Acid

The following simple experiment, which may be easily performed,

will serve to prove the theory that there is a magnetic field produced
about a conductor carrying a current, and that there is a definite
relation between the direction of the current in the conductor and the
direction, or polarity, of the magnetic field produced by the current.
The current in the experiment is to be produced by a battery
consisting of a small copper and zinc plate fastened to the under
side of a large flat cork, as shown in the sketch, the whole being
placed in a glass or rubber vessel partly filled with diluted sulphuric
acid. A small coil of wire is formed and mounted on top of the cork,
and its terminals are connected to the copper and zinc plates. The
electromotive force generated will cause a current to circulate
through the coil from the copper plate to the zinc plate. If the poles of
a permanent magnet be presented in turn to the same side of the
coil it will be found that there is a force of attraction between one
pole of the permanent magnet and the coil, and a force of repulsion
between the other pole and the coil. If the same operation be
performed on the opposite side of the coil, it will be found that the
force between the poles of the magnet and the coil are just the
reverse of what they were in the first case; that is, the pole that
attracted the coil in the first case will now repel it, and the one that
repelled it, will now attract it. Applying one of the fundamental laws of
magnetism—like poles attract and unlike repel each other—it can be
readily seen that the two sides of the coil are of opposite magnetic
polarity.
If the direction of the current around the coil be changed, the
action between the coil and the magnet will be opposite to what it
was originally, and if the plates be placed in clean water, there will be
no current and no attraction or repulsion between the coil and the
poles of the magnet.
 Double Lock for a Shed

Four boys using the same shed as their workshop wished to lock it
so that any one of them could enter alone. Usually only two keys are
supplied with a lock, so two locks were purchased and applied to the
staples as shown. Each boy was provided with a key and could enter
at his pleasure.—Contributed by George Alfred Moore, Versailles, O.
 Ferrules for Tool Handles

Discarded metal caps from broken gas-mantle holders should be

saved, as they will come in handy for several purposes, such as
ferrules on wood handles, and the like. The wire screen is removed
from the end, and the cap is fastened to the handle with a nail or
screw.—Contributed by James M. Kane, Doylestown, Pa.
 Mallet Made from Wagon-Wheel Felly and Spoke

A Well-Shaped Mallet Made from a Section of a Wagon-Wheel Felly and

Spoke

When in need of a mallet and if an old broken and discarded

wagon wheel is at hand, one can be made quickly as follows: Cut
through the rim at A and B, and through the spoke at any distance
desired, as at C, for instance. The spoke is dressed into the shape of
a handle and sandpapered smooth. The section of the felly is used
as head and is shaped properly and fastened to the handle with two
nails.—Contributed by Mark Gluckman, Jersey City, New Jersey.
 A Mystery Sounding Glass
Procure a thin, tapering drinking glass, a piece of thin, black
thread, about 2 ft. long, and a long lead pencil. Cut a small groove
around the pencil near one end. Make a slip noose in each end of
the thread and slip one into the notch and place the thin glass in the
other with the thread near the top. When the pencil is revolved slowly
the thread will be wound on it slightly and it will slip back with a jerk
that produces a ring in the glass. This may be kept up indefinitely.
The movement necessary is so small that it is imperceptible. The
glass can be made to answer questions by two rings for “yes” and
one ring for “no.”

¶A lighted match held to the outside of a fish-pole joint causes an

expansion of the outer ferrule and allows the pole to be readily pulled
apart.
 Repairing a Broken Canoe Paddle

While paddling a rented canoe one day the paddle struck a rock
and snapped in two a little below the center of the handle. The
boatman laughed at the idea of trying to fix it, but after paying his
price for the paddle I decided to try mending it. The barrel of an old
bicycle pump was procured and I found that it fitted over the paddle
at the break a trifle loosely. It was pushed on the handle out of the
way. Then with a No. 8 bit I bored a hole 8 in. deep in the end of
each broken part. Into these holes, which formed one cavity when
the broken ends were brought together, was forced and glued a
tight-fitting 16-in. dowel pin. The outside of the handle was then
wrapped with tape for about 10 in. each side of the break, and the
pump barrel was forced down over this tape until it completely and
firmly enveloped the broken ends.—Contributed by Clarence G.
Meyers, Waterloo, Iowa
 Tightening Lever for Tennis Nets

The Upper Rope on a Tennis Net Held Taut with a Lever on the Post

Tennis nets are always sagging and to keep them at the proper
height requires considerable attention, especially so where the posts
are not solidly set in the ground. A very effective net tightener, and
one that is easy to make is the lever shown in the illustration. One
end of a piece of hardwood board is shaped into a handle the other
end being left large. In the latter a hole is cut to fit loosely over the
post for the net. The upper end of the post is notched and a sheave
pulley is placed in it so that the groove will be in line with the net.
The upper rope on the net is run over the pulley and is attached to
the lever handle. A downward pressure on the handle draws the
rope taut and locks it on the post. It is easily removed from the post
and can be left attached to the rope and rolled up in the net when not
in use.
 A Desk Watch Holder

A watch holder for the desk is a great convenience for the busy
worker, and many calendar devices are sold for this purpose, yet
they are no more efficient than the one illustrated, which can be
made from an ordinary spindle desk file. If the wire is too long it can
be cut off and the bend made in it to form a hook for the watch ring.
 Cleaning Silverware
To clean silverware or anything made of the precious metals, such
as jewelry, etc., is very simple with the following method: Place a
piece of zinc in a cup, dish, or any glazed ware; put in the articles to
be cleaned, and pour over them a hot solution of water and
carbonate of soda—washing soda—in proportions of one
tablespoonful of soda to ¹⁄₂ gal. of water. This is a solution and
method used by many jewelers for cleaning pins, rings, chains, and
many other small articles made in gold and silver.

¶A machine should never be stopped in the midst of a fine cut.

 An Eight-Pointed Star Kite
By CHARLES M. MILLER

Nearly every boy can make kites of the several common varieties
without special directions. For the boy who wants a kite that is not
like those every other boy makes, an eight-pointed star kite,
decorated in an original and interesting manner, in various colors, is
well worth while, even if it requires more careful work, and extra
time. The star kite shown in Fig. 1 is simple in construction, and if
carefully made, will fly to a great height. It is balanced by streamers
instead of the common type of kite tail. Any regular-shaped kite
should be laid out accurately, as otherwise the error appears very
prominent, and unbalances the poise of the kite.
The frame for this star kite is made of four sticks, joined, as
indicated in Fig. 5, with strings running from one corner to the
second corner beyond, as from A to C, from C to E, etc. A little
notching of each pair of sticks lessens the thickness of the sticks at
the center crossing, and strengthens the frame, The sticks are ¹⁄₄ by
¹⁄₂ in. by 4 ft. long, They are set at right angles to each other in pairs,
and lashed together with cord, and also held by a ³⁄₄-in. brad at the
center. The strings that form the sides of the squares, A to G, and B
to H, must be equal in length when tied. The points where the strings
forming the squares cross each other and the sticks are also tied.
The first cover, which is put on with paste, laying it out on a
smooth floor or table as usual in kite making, is plain light-colored
paper. The darker decorations are pasted onto this. The outside
edges of the cover are turned over the string outline, and pasted
down. The colors may be in many combinations, as red and white,
purple and gold, green and white, etc. Brilliant and contrasting colors
are best. The decoration may proceed from the center out, or the
reverse. The outside edge in the design shown has a 1¹⁄₂-in. black
stripe. The figures are black. The next octagonal black line binds the
design together. The points of the star are dark blue, with a gilt stripe
on each. The center design is done in black, dark blue, and gilt.