Diabetes Mellitus and Endocrine Disorders (Thyroid, Adrenal, Pituitary, Parathyroid) MCQs

Medicine · 221 free questions with answers & explanations.

1. A 58-year-old man with type 2 diabetes mellitus on metformin and glipizide presents with a HbA1c of 9.2%. He has stage 3 CKD (eGFR 38 mL/min/1.73 m²) and mild heart failure (EF 40%). Which oral antidiabetic agent should be avoided due to concern for lactic acidosis risk in this patient?
2. A 34-year-old woman presents with amenorrhea, galactorrhea, and a prolactin level of 210 ng/mL. MRI pituitary shows a 12 mm intrasellar lesion. Which of the following is the most appropriate first-line treatment?
3. A 42-year-old woman has a 3 cm right thyroid nodule. Fine-needle aspiration (FNA) cytology reports 'follicular neoplasm' (Bethesda IV). The most appropriate next step is:
4. A 55-year-old man presents with hypertension (BP 178/104 mmHg), hypokalemia (K⁺ 2.9 mEq/L), and metabolic alkalosis. 24-hour urinary aldosterone is elevated and plasma renin activity is suppressed. CT abdomen shows a 1.8 cm left adrenal adenoma. The most appropriate definitive treatment is:
5. A 55-year-old man with long-standing type 2 diabetes presents with progressive renal impairment (eGFR 38 mL/min). His HbA1c is 7.9%. Which antidiabetic agent requires dose adjustment and should be used with caution below eGFR 45 mL/min due to risk of lactic acidosis?
6. A 42-year-old woman is found to have a suppressed TSH of 0.02 mIU/L with a free T4 of 2.6 ng/dL and free T3 of 9.8 pg/mL. She has a multinodular goitre and no exophthalmos. Technetium scan shows multiple autonomous hyperfunctioning nodules. Which treatment is most appropriate as first-line definitive therapy?
7. A patient with known adrenocortical insufficiency is undergoing elective cholecystectomy under general anaesthesia. His usual maintenance dose is hydrocortisone 20 mg morning and 10 mg afternoon. What is the recommended perioperative steroid coverage for this major surgical stress?
8. A 38-year-old man presents with hypertension (180/110 mmHg), hypokalemia (K+ 2.8 mEq/L), and metabolic alkalosis. Plasma aldosterone-to-renin ratio (ARR) is markedly elevated at 65 (ng/dL)/(ng/mL/h). CT adrenal shows a 1.4 cm left adrenal adenoma. What is the gold-standard next step to confirm lateralization before surgery?
9. A 50-year-old woman has serum calcium 11.8 mg/dL, phosphate 2.1 mg/dL, PTH 145 pg/mL (normal 10–65), and 24-hour urine calcium 420 mg/day. Dual-energy X-ray absorptiometry (DEXA) shows T-score of −2.7 at the distal radius. She is asymptomatic. What is the most appropriate management?
10. A 58-year-old man with type 2 diabetes is started on empagliflozin. The EMPA-REG OUTCOME trial demonstrated that this drug's cardiovascular benefit is primarily attributed to which mechanism?
11. A 42-year-old woman presents with hypertension, hypokalemia, and metabolic alkalosis. Plasma aldosterone-to-renin ratio (ARR) is elevated at 35 (ng/dL)/(ng/mL/hr). Confirmatory testing with salt loading shows failure to suppress aldosterone below 10 ng/dL. CT adrenals show bilateral adrenal hyperplasia. What is the next best step?
12. A 35-year-old woman is found to have a serum calcium of 11.2 mg/dL on a routine check. PTH is 82 pg/mL (elevated). 24-hour urinary calcium is 75 mg/day (low). Urine calcium-to-creatinine clearance ratio is 0.005. What is the most likely diagnosis?
13. Which of the following best describes the mechanism of action of pegvisomant in acromegaly?
14. A patient with Addison's disease presents in Addisonian crisis. After initial resuscitation with IV normal saline and hydrocortisone, laboratory results show Na 128 mEq/L. What is the most appropriate further management?
15. A 52-year-old woman with type 2 diabetes on metformin and sitagliptin presents with recurrent hypoglycaemia and weight loss. Fasting insulin is markedly elevated; C-peptide is suppressed. Plasma proinsulin:insulin ratio is 0.2. Which diagnosis does this biochemical pattern confirm?
16. The ACCORD trial of intensive glycaemic control (HbA1c target <6%) in type 2 diabetes was terminated early due to excess cardiovascular mortality in the intensive arm. Which pathophysiological mechanism is most implicated in this finding?
17. A 38-year-old man presents with hypertension refractory to three agents, hypokalaemia (K 2.8 mEq/L), and metabolic alkalosis. Plasma aldosterone:renin ratio is 45 ng/dL per ng/mL/hr. CT abdomen shows bilateral adrenal hyperplasia. What is the definitive localisation test before treatment decision?
18. McCune-Albright syndrome results from a postzygotic gain-of-function mutation in GNAS1. Constitutive activation of Gsα leads to autonomous hyperfunction of multiple endocrine organs. Which clinical triad is MOST characteristic?
19. A 29-year-old woman is found to have hypercalcaemia (serum Ca 11.2 mg/dL) on routine labs. PTH is 98 pg/mL (normal 10–65). Urinary calcium:creatinine clearance ratio (UCCR) is 0.005 (normal >0.01). Her mother and aunt both have asymptomatic hypercalcaemia. What is the most likely diagnosis?
20. A 52-year-old man with type 2 diabetes and an eGFR of 48 mL/min/1.73 m² is started on empagliflozin. The primary mechanism by which this drug reduces cardiovascular mortality (as shown in the EMPA-REG OUTCOME trial) is BEST explained by:
21. A 38-year-old woman presents with weight gain, easy bruising, proximal muscle weakness, and hypertension. 24-hour urinary free cortisol is 4× the upper limit of normal. Late-night salivary cortisol is elevated on two occasions. The next most appropriate investigation to establish the CAUSE is:
22. A patient with primary hyperaldosteronism undergoes adrenal vein sampling (AVS). The aldosterone-to-cortisol ratio from the right adrenal vein is 8× that of the left. The most appropriate next step is:
23. A 30-year-old woman is found to have a serum calcium of 11.4 mg/dL and PTH of 92 pg/mL (normal 15–65). She is asymptomatic. PTH-rP is undetectable. Her bone density Z-score is −1.8 at the hip. According to current guidelines (AAA 2022 consensus), which criterion mandates surgical parathyroidectomy?
24. In a patient with MEN type 2A (RET proto-oncogene mutation at codon 634), which is the CORRECT sequence of prophylactic management?
25. A 58-year-old man with type 2 diabetes is on metformin and sitagliptin. His HbA1c is 8.4%, eGFR is 52 mL/min/1.73m², and he has established cardiovascular disease (prior MI). According to ADA 2024 guidelines, which agent should be PREFERENTIALLY added to reduce cardiovascular mortality in this patient?
26. A 34-year-old woman presents with episodic headache, sweating, and palpitations. Her 24-hour urine shows elevated metanephrines. CT scan reveals a 3.5 cm right adrenal mass. She also has a past history of medullary thyroid carcinoma. Which genetic mutation should be tested first?
27. A 45-year-old woman with Graves' disease is being managed with carbimazole. She develops agranulocytosis. Besides stopping carbimazole, what is the IMMEDIATE next step in management?
28. A patient presents with hypercalcemia, low PTH, high PTHrP (PTH-related protein), and elevated 1,25-dihydroxyvitamin D. The most likely etiology of hypercalcemia is:
29. A 28-year-old woman presents with secondary amenorrhea, galactorrhea, and infertility. MRI shows a 6 mm pituitary adenoma. Serum prolactin is 180 ng/mL. The drug of choice and mechanism of action is:
30. A 35-year-old woman presents with hypertension, hypokalemia, and suppressed plasma renin activity. Aldosterone-to-renin ratio (ARR) is markedly elevated. CT adrenals show a 1.8 cm right adrenal adenoma. Which confirmatory test is the most appropriate next step before adrenalectomy?
31. A 28-year-old woman is found to have a serum calcium of 10.9 mg/dL on routine labs. PTH is elevated at 95 pg/mL. She is asymptomatic. A 24-hour urinary calcium is 60 mg/day (hypocalciuria). Her mother had similar findings. CASR gene mutation analysis is positive. What is the most appropriate management?
32. A 52-year-old man with type 2 diabetes is on metformin and a sulfonylurea. HbA1c is 8.4%. He has established atherosclerotic cardiovascular disease (ASCVD) — a previous MI 2 years ago. Which addition to his regimen has the MOST evidence for cardiovascular mortality reduction per current ADA guidelines?
33. A 40-year-old woman is evaluated for episodic hypertension, diaphoresis, and headache. 24-hour urine metanephrines are 4× the upper limit of normal. CT shows a 4 cm right adrenal mass. After adequate alpha-blockade with phenoxybenzamine for 2 weeks, surgery is planned. Which is the most appropriate intraoperative maneuver when the adrenal vein is ligated?
34. According to the Endocrine Society guidelines, which finding in a patient with subclinical hypothyroidism (TSH 6.5 mIU/L, free T4 normal) is the STRONGEST indication to initiate levothyroxine therapy?
35. A 55-year-old woman with type 2 diabetes and eGFR 45 mL/min/1.73m² is started on a SGLT-2 inhibitor. Which haemodynamic mechanism most directly reduces her cardiorenal risk beyond glycaemic control?
36. A 30-year-old woman has recurrent symptomatic hypoglycaemia after prolonged fasting. Supervised 72-hour fast: glucose 41 mg/dL, insulin 18 µU/mL, C-peptide 3.8 ng/mL, proinsulin 22 pmol/L, β-hydroxybutyrate 0.2 mmol/L, negative sulfonylurea screen. Which is the most likely diagnosis?
37. A patient with primary adrenal insufficiency has been stable on hydrocortisone 20 mg/10 mg and fludrocortisone 0.1 mg daily. She develops vomiting, fever 38.8°C, and BP 80/50 mmHg. Which is the most appropriate immediate management?
38. A 40-year-old with Graves' disease is 10 weeks pregnant. FT4 is 2.8 times ULN. Which antithyroid drug and dose strategy best balances fetal and maternal risk in the first trimester?
39. A 45-year-old man has hypertension, hypokalaemia, and metabolic alkalosis. Aldosterone-to-renin ratio (ARR) is 45 (ng/dL per ng/mL/h). Which confirmatory test has the highest specificity for primary hyperaldosteronism?
40. A 52-year-old man with type 2 diabetes on metformin has HbA1c 8.9% and eGFR 62 mL/min. He has established atherosclerotic cardiovascular disease. According to current ADA/ESC guidelines, the next medication with the strongest evidence for reducing MACE in this patient is:
41. A 38-year-old woman presents with episodic headaches, diaphoresis, and palpitations. BP is 195/110 mmHg during the attack. Plasma metanephrines are elevated 4-fold. After confirming the diagnosis biochemically, the FIRST pharmacological step before proceeding to adrenalectomy is:
42. A 44-year-old woman is found to have a 2.1 cm right adrenal adenoma on CT done for an unrelated reason. She has no symptoms of adrenal hormone excess. Biochemical workup shows: suppressed plasma renin, aldosterone-to-renin ratio 35 (normal <20), and 24-h urine aldosterone elevated. Cortisol suppresses adequately on overnight 1-mg DST. The most appropriate next step in management is:
43. A 27-year-old man presents with polyuria, polydipsia, and hypernatremia (Na+ 152 mEq/L). Water deprivation test fails to concentrate urine above 300 mOsm/kg. Urine osmolality rises to 650 mOsm/kg after exogenous desmopressin. This response is consistent with:
44. A 34-year-old woman with Graves' disease is 8 weeks pregnant. She is currently on propylthiouracil. Thyroid function shows TSH <0.01, fT4 2.8 times upper limit. According to current endocrine guidelines, the preferred management in the second trimester of this patient is:
45. A 42-year-old woman with type 2 diabetes on metformin 2g/day has HbA1c of 8.9%. Her eGFR is 52 mL/min/1.73m². She has established atherosclerotic cardiovascular disease. Which additional agent provides the strongest evidence for cardiovascular mortality reduction in this patient?
46. A 35-year-old man presents with episodic hypertension (BP up to 220/120 mmHg), diaphoresis, and palpitations. 24-hour urine shows elevated normetanephrine 3200 µg/day (normal <600). CT scan reveals a 4.2 cm right adrenal mass. Before adrenalectomy, the FIRST pharmacological step is:
47. A 58-year-old woman with a history of neck irradiation presents with fatigue, cold intolerance, and constipation. TSH is 48 mIU/L, free T4 is 0.4 ng/dL. Anti-TPO antibodies are negative. What is the most likely underlying mechanism?
48. A 28-year-old man with new-onset hypertension has serum potassium of 2.9 mEq/L despite oral replacement. Aldosterone:renin ratio (ARR) is 42 (normal <20). CT adrenals shows bilateral adrenal hyperplasia. What is the next best step?
49. A 45-year-old man with central obesity, moon facies, and striae is found to have 24-hour urinary free cortisol of 450 µg/day (normal <100). ACTH level is undetectable (<5 pg/mL). The most likely diagnosis is:
50. A patient with MEN-1 syndrome undergoes surveillance. Which of the following combinations is the HALLMARK triad of MEN-1?
51. A 54-year-old man with type 2 diabetes on metformin 1 g twice daily has an eGFR of 32 mL/min/1.73 m². His HbA1c is 8.2%. Which statement about metformin use in this patient is most accurate per current ADA/KDIGO 2024 guidance?
52. A 40-year-old woman presents with episodic severe headache, diaphoresis, and palpitations. 24-hour urine metanephrines are markedly elevated. CT abdomen shows a 3.5 cm right adrenal mass. Pre-operative alpha-blockade is planned. Which alpha-blocker is preferred and what is the recommended minimum duration before surgery?
53. A 35-year-old woman is found to have suppressed TSH (0.01 mU/L) and elevated free T4 during routine screening; she is asymptomatic. Technetium scan shows diffusely increased uptake. Anti-TSH receptor antibodies are positive. Which of the following represents the strongest indication to start treatment in subclinical hyperthyroidism from Graves' disease in her age group per current guidelines?
54. A 28-year-old woman presents with secondary amenorrhoea, galactorrhoea, and a serum prolactin of 180 ng/mL. MRI pituitary reveals a 12 mm macroadenoma. She wishes to preserve fertility. What is the first-line management?
55. A 50-year-old man with Cushing's disease (ACTH-dependent hypercortisolism from a pituitary microadenoma) undergoes successful trans-sphenoidal resection. Post-operatively, serum cortisol falls to 1.2 µg/dL on day 3. What does this low cortisol indicate and how should it be managed?
56. A 62-year-old woman presents with fatigue and constipation. Investigations reveal: serum calcium 11.8 mg/dL, PTH 95 pg/mL (normal 10–65), phosphate 2.4 mg/dL, 24-hour urine calcium 350 mg. Which single finding best distinguishes primary hyperparathyroidism from familial hypocalciuric hypercalcaemia (FHH)?
57. The EMPA-REG OUTCOME trial demonstrated that empagliflozin reduced cardiovascular mortality in type 2 diabetics with established CVD. The PRIMARY mechanism responsible for this cardiac benefit is best explained by:
58. A 38-year-old woman has episodic hypertension, headache, and palpitations. 24-hour urine metanephrines are markedly elevated. CT abdomen reveals a 4 cm left adrenal mass. Prior to surgical resection, the CORRECT sequence of preoperative pharmacological preparation is:
59. A 55-year-old man with a 2 cm pituitary macroadenoma has bitemporal hemianopia and serum prolactin of 320 ng/mL. The MOST appropriate initial management is:
60. In primary hyperaldosteronism, the Fludrocortisone Suppression Test (FST) is used for biochemical confirmation. A positive (diagnostic) test result is defined as plasma aldosterone remaining above:
61. A 45-year-old woman has serum calcium 11.8 mg/dL, PTH 95 pg/mL (normal 10–65), phosphate 2.1 mg/dL, and 24-hour urine calcium 420 mg. She is asymptomatic. According to current guidelines (2022 Fourth International Workshop), which criterion alone is sufficient to recommend parathyroidectomy?
62. A patient with type 2 diabetes has eGFR 38 mL/min/1.73m² and urine ACR 280 mg/g. HbA1c is 8.1%. According to current KDIGO 2022 and ADA 2024 guidelines, which combination of agents is MOST appropriate to slow CKD progression?
63. A 30-year-old pregnant woman (20 weeks) is found to have subclinical hypothyroidism (TSH 5.8 mIU/L, free T4 normal, TPO antibodies positive). According to current ATA 2017 guidelines, the appropriate management is:
64. The ACCORD trial was terminated early because intensive glycemic control (HbA1c target <6%) significantly increased which outcome compared to standard control?
65. A 58-year-old woman with type 2 diabetes and CKD stage 3b (eGFR 38 mL/min/1.73 m²) is already on metformin (dose-reduced) and empagliflozin. Her HbA1c is 8.2%. Per ADA 2024 guidelines, which additional agent is preferred for further glycemic and cardiorenal protection in this patient?
66. Finerenone, a non-steroidal mineralocorticoid receptor antagonist, demonstrated reduction in CKD progression and cardiovascular events in patients with type 2 diabetes and CKD in which landmark trial?
67. A 45-year-old woman presents with episodic severe headache, palpitations, diaphoresis, and hypertension (BP 220/130 mmHg). 24-hour urine metanephrines are 8× the upper limit of normal. Imaging reveals a 4 cm right adrenal mass. What is the correct sequence of management before surgical resection?
68. A patient with Cushing's syndrome secondary to ectopic ACTH secretion from a small cell lung carcinoma has a plasma ACTH of 380 pg/mL, serum cortisol 78 µg/dL, and fails high-dose dexamethasone suppression. Which drug acts by inhibiting 11β-hydroxylase to rapidly reduce cortisol in this setting?
69. A 32-year-old woman with Graves' disease on carbimazole develops fever, severe sore throat, and absolute neutrophil count of 280 cells/µL. What is the most appropriate immediate step?
70. Primary hyperaldosteronism is confirmed biochemically. CT scan shows a normal-appearing bilateral adrenal glands. What is the most appropriate next investigation to guide definitive management?
71. A 55-year-old man with type 2 diabetes on metformin has eGFR of 32 mL/min/1.73m². His HbA1c is 8.2%. Which additional glucose-lowering agent is preferred according to current ADA/KDIGO guidelines for its dual renal and cardiovascular protection at this level of kidney function?
72. A 30-year-old woman presents with episodic hypertension, diaphoresis, headache and palpitations. 24-hour urine metanephrines are markedly elevated. CT abdomen reveals a 4 cm adrenal mass. Which pharmacological preparation is MANDATORY before surgical resection?
73. A 42-year-old woman has fatigue, weight gain, dry skin and constipation. TSH is 52 mIU/L and free T4 is undetectable. Anti-TPO antibodies are 1200 IU/mL. She is started on levothyroxine. After 6 weeks, the MOST appropriate monitoring parameter to guide dose titration is:
74. A 28-year-old man has hypokalemia (K+ 2.8), hypertension, metabolic alkalosis, and suppressed plasma renin activity. Plasma aldosterone-to-renin ratio (ARR) is markedly elevated. Adrenal CT shows bilateral adrenal hyperplasia. The FIRST-LINE medical treatment for this subtype of primary hyperaldosteronism is:
75. A 35-year-old woman with Graves' hyperthyroidism is 8 weeks pregnant. Which antithyroid drug is preferred in the FIRST trimester to minimise fetal risk?
76. A 50-year-old man with type 2 diabetes, known heart failure with reduced ejection fraction (HFrEF, EF 35%), and eGFR 55 is on metformin and insulin. Which additional agent has demonstrated mortality benefit specifically in HFrEF with diabetes in the EMPEROR-Reduced and DAPA-HF trials?
77. A 45-year-old man has hypercalcemia (Ca²⁺ 3.1 mmol/L), nephrolithiasis, and an incidental fracture. PTH is 12× the upper limit of normal. The MOST appropriate definitive management is:
78. A 38-year-old woman with type 1 diabetes is found to have a fasting plasma glucose of 180 mg/dL despite being on insulin. She reports that her blood glucose is normal at bedtime but elevated each morning. Continuous glucose monitoring shows a nadir at 2–3 AM followed by a rise. Which mechanism best explains this pattern?
79. A 52-year-old man with type 2 diabetes on metformin develops an HbA1c of 8.4%. His eGFR is 48 mL/min/1.73 m². He has established atherosclerotic cardiovascular disease. Which agent, added to metformin, has the strongest evidence for reducing major adverse cardiovascular events AND has no dose adjustment required for this eGFR?
80. A 45-year-old woman has a serum calcium of 11.4 mg/dL, phosphorus 2.1 mg/dL, PTH 145 pg/mL (normal 15–65), and 24-hour urine calcium 380 mg/day. She is asymptomatic. Which finding would be the strongest indication for parathyroidectomy?
81. A 30-year-old man is found to have a serum cortisol of 850 nmol/L at 8 AM. A 1 mg overnight dexamethasone suppression test shows a cortisol of 180 nmol/L. Urinary free cortisol is three times the upper limit. ACTH is suppressed at <5 pg/mL. The most likely diagnosis is:
82. A patient with Graves' disease is started on carbimazole. After 6 weeks, TSH remains suppressed and FT4 is still elevated. The patient asks about definitive therapy. Which statement regarding radioiodine therapy in Graves' disease is CORRECT?
83. A 28-year-old woman presents with secondary amenorrhea, galactorrhea, and headache. MRI shows a pituitary lesion measuring 14 mm. Prolactin is 3200 mIU/L. Which statement about management is MOST accurate?
84. A 52-year-old man with type 2 diabetes on metformin 1 g twice daily has HbA1c 8.4%. He has eGFR 48 mL/min/1.73m², UACR 180 mg/g, and established atherosclerotic cardiovascular disease. Which add-on agent provides both cardiovascular and renal outcome benefits supported by dedicated CVOT/renal trials?
85. A patient with Cushing's disease undergoes transsphenoidal surgery. Post-operatively, serum cortisol at 0800 h is 1.2 µg/dL and the patient develops nausea, hyponatremia and fatigue. Which statement about post-operative management is MOST accurate?
86. A 38-year-old woman presents with episodic headaches, sweating and palpitations. 24-hour urine metanephrines are markedly elevated. CT abdomen shows a 4 cm right adrenal mass. Which is the MOST important pre-operative preparation step before surgical resection?
87. A 45-year-old woman is found to have serum calcium 11.4 mg/dL and PTH 92 pg/mL (normal 10–65) on routine screening. She is asymptomatic with no nephrolithiasis, serum creatinine is normal, and BMD T-score is −1.8 at the lumbar spine. Which management is recommended per current guidelines for asymptomatic primary hyperparathyroidism?
88. Which feature best distinguishes a TSH-secreting pituitary adenoma (TSHoma) from thyroid hormone resistance syndrome as a cause of elevated TSH with elevated free T4?
89. A 30-year-old woman develops polydipsia and polyuria with urine output of 6 L/day after resection of a craniopharyngioma. Plasma osmolality is 302 mOsm/kg, urine osmolality is 85 mOsm/kg. After 8 hours of water deprivation the urine osmolality rises to only 102 mOsm/kg. After desmopressin injection urine osmolality rises to 580 mOsm/kg. The diagnosis is:
90. A 58-year-old man with type 2 diabetes on metformin presents with HbA1c of 9.2%. He has established atherosclerotic cardiovascular disease (ASCVD). Which add-on agent is recommended by the 2023 ADA Standards of Care as the preferred second agent specifically because it reduces major adverse cardiovascular events (MACE) independent of glycemic control?
91. A 34-year-old woman is found to have persistent hypercalcemia (serum Ca 11.8 mg/dL) with elevated intact PTH of 92 pg/mL (normal 15–65), low-normal phosphate, and elevated urine calcium excretion. 24-hour urine calcium is 420 mg. Which diagnosis best explains this combination?
92. A 45-year-old woman with known MEN1 syndrome undergoes biochemical screening. She is found to have elevated fasting gastrin levels with a secretin stimulation test showing a paradoxical rise in gastrin >200 pg/mL. Which pancreatic tumor is responsible?
93. A 28-year-old man presents with headache, diaphoresis, and hypertension (200/120 mmHg). Plasma metanephrine is markedly elevated. Pre-operatively, adequate alpha-blockade is established with phenoxybenzamine. The next essential step before surgery is:
94. A 52-year-old woman is referred for evaluation of Cushing syndrome. The overnight 1 mg dexamethasone suppression test (DST) shows cortisol of 5.8 mcg/dL (normal suppression <1.8 mcg/dL). Her ACTH is undetectable. The most likely etiology is:
95. A 40-year-old woman with Graves disease refractory to antithyroid drugs is being considered for radioactive iodine (RAI) therapy. She has moderate-to-severe active thyroid eye disease (TED). Which statement regarding RAI in this setting is CORRECT?
96. A 55-year-old man with type 2 diabetes is started on canagliflozin. After 6 weeks he presents with perineal swelling, redness, crepitus, and high fever. What is the most important complication to recognize?
97. A 58-year-old man with type 2 diabetes on metformin 1000 mg twice daily and sitagliptin has an HbA1c of 8.9%. He has established cardiovascular disease (prior MI 2 years ago) and an eGFR of 52 mL/min/1.73m². According to current ADA/ACC guidelines, which add-on agent provides the strongest evidence for cardiovascular mortality reduction in this patient?
98. A 32-year-old woman presents with fatigue, weight gain, and a serum TSH of 6.8 mIU/L (normal 0.4–4.0) with free T4 of 12 pmol/L (normal 12–22). Anti-TPO antibodies are strongly positive. She is trying to conceive. The most appropriate management is:
99. A 45-year-old hypertensive man has an incidentally discovered 2.8 cm left adrenal mass. Plasma aldosterone-to-renin ratio (ARR) is 38 (normal <30), 24-hour urinary cortisol is normal, plasma metanephrines are normal, and CT shows a homogeneous lipid-rich nodule. The next best diagnostic step is:
100. A 28-year-old woman develops hypertension, central obesity, purple striae, and plethora. Her midnight serum cortisol is 210 nmol/L (normal < 50) and 24-hour urinary free cortisol is elevated on two separate collections. Low-dose DST shows non-suppression. High-dose DST (8 mg dexamethasone) shows cortisol suppression to 40% of baseline. The most likely diagnosis is:
101. A 50-year-old man presents with headaches, jaw widening, and ring size increase over recent years. IGF-1 is three times the upper limit of normal and GH fails to suppress below 0.4 µg/L after a 75 g oral glucose load. MRI shows a 12 mm pituitary macroadenoma. Which first-line surgical outcome indicator determines the need for adjuvant somatostatin receptor ligand therapy?
102. A 55-year-old woman on long-term lithium for bipolar disorder presents with polyuria (5 L/day), polydipsia, and a serum sodium of 148 mEq/L. Urine osmolality after overnight water deprivation is 180 mOsm/kg. After exogenous desmopressin (DDAVP), urine osmolality rises to 600 mOsm/kg. The diagnosis is:
103. A 40-year-old woman presents with symptomatic hypercalcaemia (serum calcium 3.1 mmol/L, corrected). PTH is 98 pg/mL (elevated). 24-hour urinary calcium is 620 mg/day. The most appropriate definitive management is:
104. A 58-year-old man with type 2 diabetes on metformin has a HbA1c of 8.6%. He has an eGFR of 52 mL/min/1.73m², established atherosclerotic cardiovascular disease, and BMI 32 kg/m². Which agent should be added FIRST according to current ADA guidelines?
105. A 34-year-old woman presents with hypokalemia, hypertension resistant to four drugs, and suppressed plasma renin activity. Aldosterone-to-renin ratio (ARR) is markedly elevated at 42 ng/dL per ng/mL/h. Confirmatory testing with salt loading is positive. Adrenal CT shows a 1.8 cm left adrenal adenoma. What is the next BEST step?
106. A 45-year-old woman is evaluated for osteoporosis. Serum calcium is 11.2 mg/dL, phosphorus 2.4 mg/dL, intact PTH is 95 pg/mL (normal 15–65). 24-hour urine calcium is 340 mg. Dual X-ray absorptiometry (DXA) shows T-score of −2.7 at the lumbar spine. Which feature MOST favors surgical parathyroidectomy in asymptomatic primary hyperparathyroidism per current guidelines?
107. A 28-year-old woman has a 2.3 cm thyroid nodule on ultrasound. Fine needle aspiration (FNA) cytology is reported as Bethesda category IV (follicular neoplasm). Molecular testing with Afirma Gene Sequencing Classifier returns 'suspicious.' What is the MOST appropriate next step?
108. A 52-year-old man presents with central obesity, bruising, hypertension, and hyperglycemia. 24-hour urinary free cortisol is 450 μg/day (normal <50). Overnight 1 mg dexamethasone suppression test fails to suppress cortisol below 1.8 μg/dL. Plasma ACTH is undetectable. What is the MOST likely diagnosis?
109. A 58-year-old man with type 2 diabetes has eGFR 38 mL/min/1.73m² and HbA1c 8.4%. His current regimen includes metformin and sitagliptin. Which antidiabetic agent should be added for its demonstrated cardiovascular and renoprotective benefit in this setting?
110. A 34-year-old woman presents with resistant hypertension, spontaneous hypokalaemia (K⁺ 2.9 mEq/L), and suppressed plasma renin activity. CT abdomen shows a 1.8 cm right adrenal adenoma. Adrenal vein sampling (AVS) confirms right-sided aldosterone excess. What is the definitive treatment?
111. A 42-year-old woman is found to have a serum calcium of 11.2 mg/dL on routine testing. PTH is 98 pg/mL (normal 15–65). 24-hour urinary calcium is 390 mg. She is asymptomatic. Which finding would make her a definitive surgical candidate according to current guidelines?
112. A 29-year-old woman with Graves' disease achieves euthyroidism on carbimazole. She becomes pregnant at 8 weeks of gestation. What is the preferred management change?
113. A 55-year-old man with known type 2 diabetes presents with a fasting plasma glucose of 220 mg/dL and HbA1c of 10.2%. He has no symptoms of hyperglycaemia and no cardiovascular disease. According to ADA 2024 guidelines, what is the preferred initial therapy combination?
114. A 48-year-old woman has secondary amenorrhoea, low FSH, low LH, elevated prolactin of 210 ng/mL, and bitemporal hemianopia. MRI pituitary shows a 1.4 cm macroadenoma. What is the first-line treatment?
115. Which of the following is the most sensitive biochemical screening test for Cushing's syndrome?
116. A 38-year-old man presents with episodic headache, palpitations, and diaphoresis. BP during an episode is 220/130 mmHg. 24-hour urinary metanephrines are markedly elevated. Which genetic syndrome is most commonly associated with bilateral phaeochromocytoma?
117. A 52-year-old woman with type 2 diabetes on metformin and sitagliptin presents with HbA1c of 9.2%. She has an eGFR of 48 mL/min/1.73m² and urinary albumin-creatinine ratio of 320 mg/g. According to current ADA guidelines, which add-on therapy provides both glycaemic benefit and the strongest evidence for nephroprotection in this patient?
118. A 38-year-old man presents with episodic severe hypertension, diaphoresis, and palpitations. 24-hour urinary metanephrines are markedly elevated. CT abdomen reveals a 4.2 cm left adrenal mass. Before adrenalectomy, the sequence of pre-operative pharmacological preparation should be:
119. A 44-year-old woman is found to have a serum calcium of 11.6 mg/dL on routine testing. PTH is 92 pg/mL (normal 10–65), phosphate is low-normal, and 24-hour urinary calcium is 380 mg/day. She is asymptomatic. Which condition does this biochemical profile most specifically indicate?
120. A 29-year-old woman is diagnosed with Graves' disease. She is 10 weeks pregnant. The treatment of choice at this stage of gestation is:
121. A 56-year-old man with Nelson's syndrome after bilateral adrenalectomy for Cushing's disease presents with worsening headache and bitemporal hemianopia. MRI shows an enlarging pituitary macroadenoma. The pathophysiology responsible for this pituitary enlargement is:
122. In the RALES trial, which drug was shown to reduce mortality in patients with systolic heart failure by blocking the mineralocorticoid receptor?
123. A 52-year-old man with type 2 diabetes on metformin 1g BD and sitagliptin 100 mg OD presents with HbA1c of 9.8%. He has eGFR 48 mL/min/1.73m² and established cardiovascular disease. According to current ADA/ESC guidelines, which agent should be preferentially added to his regimen?
124. A patient with Cushing's disease undergoes pituitary surgery and achieves remission. Post-operatively, morning serum cortisol is 1.2 µg/dL. Which finding in this patient best indicates successful surgical cure?
125. A 38-year-old woman presents with weight gain, proximal muscle weakness, easy bruising, and a 2 cm right adrenal mass on CT (HU +18 on non-contrast). Serum ACTH is undetectable. Overnight 1 mg dexamethasone suppression test shows cortisol of 9.5 µg/dL. Which is the next best investigation?
126. A 45-year-old woman with known Graves' disease on carbimazole 30 mg/day for 12 months is now euthyroid. She requests definitive therapy before a planned pregnancy in 6 months. Which is the most appropriate recommendation?
127. A 28-year-old man is found to have serum calcium 11.4 mg/dL, PTH 95 pg/mL (reference 10–65), and 24-hour urine calcium 750 mg. His father and brother have similar biochemistry but no symptoms. Genetic testing reveals a heterozygous mutation in CASR. What is the diagnosis?
128. A patient with type 2 diabetes receives dulaglutide as part of the REWIND trial. This trial demonstrated which primary outcome benefit?
129. A 52-year-old man with type 2 diabetes on metformin 2 g/day has HbA1c of 8.4%. His eGFR is 38 mL/min/1.73 m². Which agent, if added, carries the STRONGEST evidence for both HbA1c reduction AND reduction in CKD progression at this eGFR?
130. A 38-year-old woman with Graves' disease is started on methimazole. After 6 weeks, her thyroid function normalises. According to current ATA guidelines, what is the recommended total duration of anti-thyroid drug therapy before considering discontinuation and testing for remission?
131. A 45-year-old man presents with episodic severe hypertension, palpitations, diaphoresis, and pallor. Plasma metanephrines are 4-fold elevated. 24-hour urine catecholamines are elevated. After alpha-blockade with phenoxybenzamine is established, what is the correct sequence for additional preoperative preparation?
132. A 30-year-old woman is evaluated for secondary amenorrhea and galactorrhea. MRI pituitary shows a 7 mm microadenoma. Serum prolactin is 142 ng/mL. She has no desire for pregnancy. What is the first-line treatment?
133. Primary hyperaldosteronism is confirmed in a 48-year-old hypertensive man. Adrenal CT shows bilateral adrenal hyperplasia. Adrenal venous sampling confirms bilateral aldosterone hypersecretion. Which management is most appropriate?
134. A 65-year-old man is found to have serum calcium of 11.6 mg/dL, PTH of 95 pg/mL (elevated), phosphate 2.4 mg/dL, and 24-hour urine calcium of 280 mg. Bone density shows T-score of –1.8 at lumbar spine. He is asymptomatic. Which criterion per 2022 guidelines mandates parathyroidectomy?
135. A 52-year-old man with type 2 diabetes on metformin and sitagliptin develops bilateral lower limb oedema and dyspnoea. HbA1c is 8.2%. His cardiologist finds preserved ejection fraction heart failure (HFpEF). Which antidiabetic agent, if added, would provide the strongest evidence-based benefit for both glycaemic control and reduction of heart failure hospitalisation in this patient?
136. A 38-year-old woman presents with weight gain, proximal myopathy, and hypertension. Overnight 1 mg dexamethasone suppression test shows cortisol of 6.8 mcg/dL (normal <1.8). Late-night salivary cortisol is elevated on two occasions. ACTH level is 85 pg/mL (normal 10–60). MRI pituitary shows a 5 mm hypointense lesion. Which additional test most reliably confirms pituitary Cushing's disease vs ectopic ACTH?
137. A patient with primary hyperparathyroidism has serum calcium 11.4 mg/dL, PTH 145 pg/mL, eGFR 52 mL/min/1.73m², T-score −2.6 at lumbar spine, and one episode of nephrolithiasis. Which of the following correctly represents a criterion for surgical intervention (parathyroidectomy) per current guidelines?
138. A 29-year-old woman with Graves' disease is in her 6th week of pregnancy. She is currently on propylthiouracil (PTU). Her FT4 is mildly elevated. What is the recommended switch in antithyroid drug management during the second trimester?
139. A 44-year-old man presents with episodic headaches, palpitations, and profuse sweating. BP during an attack is 220/120 mmHg. 24-hour urine metanephrines are markedly elevated. CT abdomen reveals a 4.5 cm right adrenal mass. Which of the following is the correct sequence of management before adrenalectomy?
140. A 58-year-old man with type 2 diabetes and an eGFR of 48 mL/min/1.73m² presents for medication review. His HbA1c is 8.2%. Which antidiabetic drug class has demonstrated cardiovascular AND renoprotective benefit independent of glycemic control in this patient?
141. A 34-year-old woman presents with hypertension, hypokalemia, and suppressed plasma renin activity. CT abdomen reveals a 1.8 cm left adrenal nodule. Aldosterone-to-renin ratio (ARR) is 40 (ng/dL)/(ng/mL/h). Which confirmatory test is recommended by Endocrine Society guidelines before proceeding to adrenal vein sampling?
142. A 26-year-old woman with Graves' disease is 8 weeks pregnant. Which of the following antithyroid drug regimens is most appropriate during the FIRST trimester?
143. A 45-year-old man with type 1 diabetes has recurrent hypoglycemia unawareness despite optimized insulin therapy. Continuous glucose monitoring (CGM) confirms nocturnal hypoglycemia. Which insulin formulation offers the most physiologic basal coverage with least nocturnal hypoglycemia risk?
144. A 52-year-old woman is found to have an incidental 2.2 cm adrenal lesion on CT (non-contrast HU = 14). Urinary catecholamines are normal, aldosterone and renin are normal, but a low-dose dexamethasone suppression test shows cortisol of 3.8 mcg/dL (non-suppressed >1.8 mcg/dL). She has hypertension and osteopenia. What is the most appropriate next management?
145. A 31-year-old woman presents with headache, visual field defect (bitemporal hemianopsia), galactorrhea, and amenorrhea. MRI shows a 14 mm pituitary adenoma with suprasellar extension. Serum prolactin is 4800 ng/mL. What is the FIRST-LINE treatment?
146. Which biochemical finding BEST distinguishes PTH-independent hypercalcemia (e.g., malignancy-associated) from primary hyperparathyroidism?
147. A 44-year-old man on chronic glucocorticoid therapy for polymyalgia rheumatica is being tapered. He develops fatigue, nausea, hypotension, and hyponatremia. Cortisol at 8 AM is 2.8 mcg/dL. Which additional electrolyte abnormality would most favor primary adrenal insufficiency over secondary?
148. A 58-year-old man with type 2 diabetes on metformin and sitagliptin presents with HbA1c 8.9%, eGFR 52 mL/min/1.73m², BMI 34 kg/m², and established atherosclerotic cardiovascular disease. Which add-on agent has the strongest evidence for reducing major adverse cardiovascular events in this patient?
149. A 34-year-old woman presents with secondary amenorrhoea, galactorrhoea, and a serum prolactin of 186 ng/mL. MRI pituitary shows a 7 mm lesion confined to the sella. She is not planning pregnancy. Which is the most appropriate initial management?
150. A 45-year-old hypertensive patient has an incidentally detected 2.8 cm adrenal mass. Biochemical workup reveals a 1 mg overnight dexamethasone suppression test with cortisol 3.2 µg/dL, normal 24-hour urine catecholamines, and normal aldosterone-renin ratio. What is the most likely diagnosis?
151. In a patient with primary hyperparathyroidism and serum calcium 11.4 mg/dL, which finding is an absolute indication for parathyroidectomy according to current guidelines?
152. A 29-year-old woman presents with weight gain, fatigue, constipation, and a TSH of 7.8 mIU/L with free T4 of 0.7 ng/dL. Anti-TPO antibodies are 640 IU/mL. She is 10 weeks pregnant. What is the target TSH for the first trimester of pregnancy in this patient?
153. A 52-year-old man with Type 2 diabetes is on metformin 2 g/day and his HbA1c is 8.4%. He has eGFR of 28 mL/min/1.73m². Which medication should be AVOIDED in adding to his regimen?
154. A 38-year-old woman has recurrent nephrolithiasis and is found to have serum calcium 11.2 mg/dL, phosphate 2.1 mg/dL, PTH 142 pg/mL, and 24-hour urinary calcium 480 mg. The most likely diagnosis and its molecular mechanism involves:
155. A 45-year-old woman presents with episodic headache, sweating, and palpitations. Her 24-hour urine metanephrines are elevated. CT scan shows a 4 cm right adrenal mass. Before surgical resection, which sequence of medical preparation is correct?
156. A 30-year-old man has Cushing's syndrome. Morning serum cortisol is 28 µg/dL. Low-dose dexamethasone suppression test (1 mg overnight) shows cortisol 22 µg/dL. High-dose DST (8 mg overnight) shows cortisol 15 µg/dL (46% suppression from baseline). Plasma ACTH is 64 pg/mL. The most likely source is:
157. A 56-year-old woman with Hashimoto's thyroiditis on levothyroxine develops palpitations and weight loss. TSH is 0.02 mU/L. Which antibody, if strongly positive, would suggest coexisting Graves' disease rather than over-replacement?
158. A 58-year-old woman with type 2 diabetes on metformin and glimepiride has an eGFR of 28 mL/min/1.73m². Her HbA1c is 8.2%. Which antidiabetic adjustment is MOST appropriate according to current guidelines?
159. A patient has Cushing's syndrome with an 8 mm ACTH-secreting pituitary adenoma confirmed on MRI. The IPSS (inferior petrosal sinus sampling) ACTH gradient is 3.5 (normal >2). Despite two attempts at trans-sphenoidal surgery, hypercortisolism persists. Which is the BEST next step?
160. Which feature BEST distinguishes familial hypocalciuric hypercalcaemia (FHH) from primary hyperparathyroidism in a patient with mild asymptomatic hypercalcaemia?
161. A 42-year-old woman is found to have a thyroid nodule. Fine-needle aspiration cytology returns Bethesda Category IV (follicular neoplasm). Which is the MOST appropriate next step?
162. A 28-year-old woman presents with weight gain, fatigue, and a serum cortisol of 820 nmol/L at 8 AM after a 1 mg overnight dexamethasone suppression test. Late-night salivary cortisol is elevated on two occasions. ACTH is undetectable. The MOST likely diagnosis is:
163. A 38-year-old woman with type 2 diabetes is started on empagliflozin. The EMPA-REG OUTCOME trial demonstrated that empagliflozin's cardiovascular benefit in diabetic patients with established CVD was primarily driven by which mechanism?
164. A 55-year-old man has central obesity, hypertension, and a morning cortisol of 650 nmol/L following a 1 mg overnight dexamethasone suppression test (normal <50 nmol/L). ACTH is 2 pmol/L (low). The most appropriate next investigation is:
165. In the management of primary hyperaldosteronism, which biochemical pattern is MOST characteristic of bilateral adrenal hyperplasia (idiopathic hyperaldosteronism) on adrenal vein sampling?
166. A patient with type 2 diabetes and stage 3b CKD (eGFR 38 ml/min/1.73m²) needs additional glycaemic control. Current therapy is metformin (dose-reduced). Which agent has demonstrated slowing of CKD progression via intraglomerular pressure reduction in addition to glycaemic control?
167. A 29-year-old woman presents with episodic severe headache, sweating, and palpitations. 24-hour urine metanephrines are elevated threefold. MIBG scintigraphy shows uptake in the right adrenal. On genetic testing, she is found to have a germline SDHB mutation. This mutation is associated with which specific risk profile?
168. A 62-year-old man with newly diagnosed papillary thyroid carcinoma (1.8 cm, pT1bN0M0, no BRAF mutation on molecular testing) undergoes total thyroidectomy. According to the 2015 ATA risk stratification, this patient is classified as:
169. A 45-year-old man with Type 2 diabetes presents with recurrent hypoglycemia despite stopping sulfonylureas. Fasting serum insulin is 48 µIU/mL (normal <25), C-peptide is 8.2 ng/mL (normal <3.0), and proinsulin is markedly elevated. Plasma sulfonylurea screen is negative. CT pancreas shows a 1.8 cm hypoenhancing lesion in the body. Which of the following criteria definitively distinguishes this from exogenous insulin administration?
170. A patient with Type 2 diabetes on metformin + empagliflozin develops a painless swelling in the perineum with foul-smelling discharge and crepitus. Temperature is 38.9°C, WBC 22,000, blood glucose 420 mg/dL. What is the most appropriate immediate management?
171. A 35-year-old woman has episodic hypertension, palpitations, and diaphoresis. 24-hour urine shows elevated metanephrines (normetanephrine 2.8× upper limit). MRI adrenal shows a 3 cm right adrenal mass. Genetic testing reveals a succinate dehydrogenase subunit B (SDHB) mutation. Which feature of her tumor most mandates closer long-term surveillance?
172. A 28-year-old woman is found to have serum calcium 11.8 mg/dL, PTH 98 pg/mL (normal 15-65), phosphate 2.1 mg/dL, and 24-hour urine calcium 82 mg/day (low). Her mother had the same findings and underwent unnecessary parathyroidectomy. The CASR gene mutation is suspected. What is the most appropriate management?
173. A 52-year-old man with known pituitary macroadenoma on cabergoline presents with a 3-month history of fatigue, increased thirst, and visual field defect. MRI shows tumor enlargement. Serum prolactin is now 82 µg/L (previously 2800 µg/L on cabergoline). What is the most likely explanation?
174. A 52-year-old man with type 2 diabetes mellitus and CKD stage 3b (eGFR 38 mL/min) is being reviewed. His HbA1c is 8.4%. Which antidiabetic agent is CONTRAINDICATED in this patient due to the risk of lactic acidosis?
175. The EMPA-REG OUTCOME trial demonstrated that empagliflozin significantly reduced cardiovascular death in type 2 diabetics. The primary mechanism responsible for this cardiorenal benefit is BEST described as:
176. A 38-year-old woman presents with weight gain, proximal myopathy, violaceous striae, hypertension, and amenorrhoea. 24-hour urinary free cortisol is elevated. Low-dose dexamethasone suppression test (1 mg overnight) shows a cortisol of 7.2 mcg/dL. The NEXT step to establish aetiology is:
177. A 45-year-old woman is found to have serum calcium of 11.2 mg/dL and PTH of 98 pg/mL (normal 15–65). She is asymptomatic with no kidney stones, bone disease, or osteoporosis. Per current AACE/ACE/EES 2022 guidelines, which criterion for parathyroidectomy does she meet?
178. A 28-year-old woman presents with palpitations, weight loss, heat intolerance, and a diffuse goitre. TSH is <0.01 mIU/L and free T4 is markedly elevated. Thyroid uptake scan shows diffusely elevated uptake. She is in the first trimester of pregnancy. The SAFEST initial management is:
179. A 52-year-old man with type 2 diabetes has eGFR 42 mL/min/1.73m² and HbA1c 9.2%. He is on metformin 1g BD. Which pharmacological intervention is MOST appropriate to add, given both glycaemic and cardio-renal benefit evidence?
180. In a patient with primary hyperaldosteronism (PA), which subtype classification requires unilateral adrenalectomy rather than medical management with mineralocorticoid receptor antagonists?
181. Which parameter in the pituitary hormone cascade is MOST directly responsible for the thyroid storm precipitation in a thyroid storm (Burch-Wartofsky score >45)?
182. A patient with Cushing's disease (pituitary ACTH-producing adenoma) has failed transsphenoidal surgery. According to current management guidelines, which medical therapy acts via a pituitary-level mechanism?
183. In primary hypoparathyroidism, the preferred long-term monitoring target for urine calcium excretion to avoid nephrocalcinosis while maintaining acceptable serum calcium is:
184. A 58-year-old man with type 2 diabetes mellitus and estimated GFR 38 mL/min/1.73m² is currently on metformin 1000 mg twice daily. His HbA1c is 8.6%. Which of the following glucose-lowering agents has the strongest evidence for reducing hospitalisation for heart failure in this patient, while also being safe at his current renal function?
185. A 34-year-old woman is found to have an incidental right adrenal mass of 2.8 cm on CT abdomen. Biochemical evaluation shows 24-hour urinary metanephrines markedly elevated. She is scheduled for laparoscopic adrenalectomy. What is the most critical pharmacological step in preoperative preparation?
186. Autonomous cortisol secretion (formerly subclinical Cushing's syndrome) is detected in a patient with an adrenal incidentaloma. According to the current European Society of Endocrinology (ESE) 2023 guidelines, which test is used as the primary screening tool for this condition?
187. A 26-year-old woman presents with secondary amenorrhoea, galactorrhoea, and a serum prolactin of 180 µg/L. MRI shows a 9 mm pituitary lesion. Which statement best describes the initial management according to current Endocrine Society guidelines?
188. Primary hyperparathyroidism is diagnosed in an asymptomatic 52-year-old woman. Serum calcium is 2.78 mmol/L (ref 2.12–2.62), creatinine clearance is 74 mL/min, and DEXA T-score at the lumbar spine is −1.8. Which of these criteria mandates surgical intervention according to the 2022 international guidelines?
189. A 58-year-old man with type 2 diabetes (HbA1c 8.6%), established CKD stage 3b, and a myocardial infarction 18 months ago is reviewed for glycaemic optimisation. Which agent provides the strongest evidence for cardiovascular mortality reduction specifically in patients with CKD and established atherosclerotic cardiovascular disease simultaneously?
190. A 44-year-old woman presents with recurrent nephrolithiasis, serum calcium 11.4 mg/dL, phosphate 2.3 mg/dL, alkaline phosphatase 340 U/L, and PTH 98 pg/mL (elevated). DEXA shows Z-score −2.1 at the radius. She is otherwise asymptomatic. According to current guidelines, which criterion mandates parathyroidectomy in asymptomatic primary hyperparathyroidism?
191. A 32-year-old woman presents with galactorrhoea, oligo-amenorrhoea, and prolactin 340 ng/mL. MRI shows an 18 mm pituitary macroadenoma. Visual field testing reveals bitemporal hemianopia. She desires fertility. What is the most appropriate initial management?
192. A 65-year-old man with Grave's disease in remission for 3 years presents with recurrence. He now has moderate proptosis, chemosis, and diplopia. Thyroid eye disease activity score (CAS) is 5/7. TSI titre is markedly elevated. Regarding mycophenolate vs. IV glucocorticoids for active moderate-to-severe Graves' orbitopathy, which statement reflects current EUGOGO 2021 guidelines?
193. A 48-year-old hypertensive woman has bilateral adrenal incidentalomas (2.3 cm and 1.8 cm), serum cortisol 3.2 µg/dL post 1 mg overnight dexamethasone suppression test, and an aldosterone-to-renin ratio of 42 (ng/dL per ng/mL/h). Her ACTH is suppressed. She has type 2 diabetes and osteopenia. What is the most accurate diagnosis and next best step?
194. A 58-year-old man with type 2 diabetes and established cardiovascular disease is started on empagliflozin. The EMPA-REG OUTCOME trial demonstrated that its cardiovascular benefit is primarily driven by reduction in which outcome?
195. A patient with primary hyperaldosteronism has a unilateral adrenal adenoma confirmed on adrenal vein sampling. Her aldosterone-to-renin ratio is 50 (ng/dL per ng/mL/hr). Adrenal vein sampling shows a lateralization ratio of 6:1. What is the MOST appropriate definitive management?
196. A 40-year-old woman presents with headache, palpitations, and episodic hypertension. 24-hour urine metanephrines are elevated. CT abdomen shows a 4 cm right adrenal mass. Prior to surgical resection, which medication must be given FIRST?
197. In the evaluation of subclinical hyperthyroidism, which TSH level defines Grade 2 (overt) suppression and carries the highest risk of atrial fibrillation and fracture?
198. A 32-year-old woman presents with polyuria, fatigue, and hypercalcemia (serum Ca 11.2 mg/dL). PTH is elevated at 115 pg/mL (normal 15–65). 24-hour urine calcium is 50 mg/24 hr (low). DEXA scan shows normal bone density. What is the MOST likely diagnosis?
199. A 58-year-old man with type 2 diabetes has eGFR 38 mL/min/1.73m². His HbA1c is 8.4%. Which antidiabetic agent should be AVOIDED due to risk of lactic acidosis at this level of renal function?
200. A 42-year-old woman presents with hypertension, hypokalemia, and an aldosterone-to-renin ratio (ARR) of 42 ng/dL per ng/mL/hr. Confirmatory testing with saline infusion shows plasma aldosterone > 10 ng/dL post-infusion. CT adrenals show a 1.6 cm right adrenal adenoma. What is the recommended next step before surgical planning?
201. A 34-year-old woman with Graves' disease on methimazole for 8 months achieves euthyroidism. She is now planning pregnancy in 3 months. Which management approach is MOST appropriate?
202. A 28-year-old man presents with episodic hypertension (200/110 mmHg), headache, palpitations, and diaphoresis. 24-hour urine metanephrines are elevated at 4.2 mg/24h (normal < 0.9). CT abdomen shows an 8 cm right adrenal mass. What is the correct sequence of preoperative management?
203. A 55-year-old woman is found to have a serum calcium of 10.9 mg/dL on routine testing. PTH is 82 pg/mL (elevated). She is asymptomatic. Her BMD shows T-score of −2.0 at lumbar spine. 24-hour urine calcium is 380 mg/day. eGFR is 68 mL/min. Which criterion for parathyroidectomy does she fulfil?
204. A 58-year-old man with type 2 diabetes on metformin and sitagliptin develops nephrotic-range proteinuria. eGFR is 38 mL/min/1.73 m². HbA1c is 8.2%. Per the 2024 ADA guidelines, which drug addition provides BOTH cardiorenal protection AND is specifically recommended at this eGFR threshold?
205. Thyroid storm scoring using the Burch-Wartofsky Point Scale assigns points across several domains. Which of the following combinations of findings yields the HIGHEST point total in a single patient?
206. A 34-year-old woman presents with episodic severe headache, diaphoresis, and palpitations. 24-hour urine metanephrines are elevated 4-fold. CT shows a 4 cm right adrenal mass. She is scheduled for adrenalectomy. Which is the CORRECT sequence of preoperative pharmacological preparation?
207. A 45-year-old man with Cushing's disease undergoes pituitary surgery but has persistent hypercortisolism. Per current guidelines, bilateral adrenalectomy is performed. Which complication unique to this situation must be closely monitored for in follow-up?
208. Primary hyperaldosteronism is confirmed biochemically. Adrenal CT shows bilateral normal glands. What is the most important next investigation before deciding on unilateral adrenalectomy?
209. A patient with MEN1 syndrome is found to have a gastrinoma. Serum gastrin is 900 pg/mL (normal <100). Secretin stimulation test shows a rise of >200 pg/mL. Which is the most common site of MEN1-associated gastrinoma?
210. A 54-year-old man with type 2 diabetes on metformin and sitagliptin has an HbA1c of 9.2%. He has an eGFR of 48 mL/min/1.73m², albuminuria of 180 mg/day, and established cardiovascular disease. According to the 2023 ADA Standards of Care, which add-on agent is MOST preferred in this patient?
211. A 42-year-old woman presents with hypertension (BP 164/98), hypokalemia (K 2.8 mEq/L), and metabolic alkalosis. Aldosterone-to-renin ratio (ARR) is 38 (ng/dL)/(ng/mL/hr). CT adrenal shows a 1.8 cm left adrenal adenoma. What is the NEXT best investigation before deciding on surgical vs medical management?
212. A 28-year-old woman is diagnosed with Graves' disease. She is 8 weeks pregnant. Which management is MOST appropriate for her hyperthyroidism?
213. A 35-year-old man with a pituitary macroadenoma (2.5 cm) has IGF-1 three times the upper limit of normal, GH nadir of 2.1 ng/mL after oral glucose tolerance test, and normal prolactin. He undergoes transsphenoidal surgery but postoperative IGF-1 remains elevated. Which medical therapy is the FIRST-LINE adjunct?
214. Which of the following best describes the pathophysiology of hypocalcemia occurring after thyroid surgery?
215. A 48-year-old woman has incidentally found a 2.5 cm left adrenal nodule on CT. CT shows Hounsfield units of 8 on unenhanced scan. She is normotensive, has no Cushingoid features. Overnight 1 mg dexamethasone suppression test shows cortisol of 4.2 μg/dL (normal <1.8 μg/dL). DHEAS is mildly low. Urinary metanephrines are normal. How should she be managed?
216. A 28-year-old pregnant woman (12 weeks gestation) is diagnosed with Graves' hyperthyroidism. She is euthyroid on propylthiouracil (PTU). At 16 weeks gestation, she is switched to methimazole. At 18 weeks, she presents with nausea, vomiting, and fever. Lab shows WBC 900/μL with neutrophils 200/μL. What is the MOST likely diagnosis and immediate action?
217. A 35-year-old man presents with weakness, weight loss, hypotension (postural drop 25 mmHg), hyperpigmentation of buccal mucosa and skinfolds, hyponatraemia (Na 128 mEq/L), and hyperkalemia (K 5.9 mEq/L). Short Synacthen test shows basal cortisol 4 μg/dL rising to 8 μg/dL at 30 minutes. ACTH is 980 pg/mL. Which is the correct steroid replacement regimen?
218. A 20-year-old man presents with polyuria (8 L/day), polydipsia, and nocturia. Urine osmolality after overnight fast is 95 mOsm/kg. After IV desmopressin (DDAVP) 2 μg, urine osmolality rises to 680 mOsm/kg. Plasma osmolality is 299 mOsm/kg. What is the diagnosis?
219. A 65-year-old woman with type 2 diabetes, heart failure with reduced ejection fraction (LVEF 32%), and eGFR 38 mL/min/1.73m² is currently on metformin, a SGLT2 inhibitor, and insulin. Which medication provides DUAL benefit — reducing HF hospitalization AND slowing CKD progression — in this patient?
220. A 28-year-old woman with known type 1 diabetes presents in DKA. ABG: pH 7.12, PCO2 22 mmHg, HCO3 8 mEq/L. Serum glucose 480 mg/dL, Na 128 mEq/L, K 5.8 mEq/L. The corrected serum sodium = 128 + [(480 − 100)/100 × 1.6] = 128 + (3.8 × 1.6) = 128 + 6.1 = 134.1 mEq/L. Regarding initial potassium management, what is the threshold serum K below which IV potassium replacement must be given BEFORE starting insulin?
221. A 34-year-old woman presents with palpitations, heat intolerance, weight loss, and bilateral proptosis. TSH is <0.01 mIU/L, free T4 is 4.8 ng/dL. Anti-TSH receptor antibody (TRAb) is strongly positive. She is 10 weeks pregnant. The safest definitive treatment for her Graves hyperthyroidism at this gestational age is: