Download VRAGEN ADRENAL GLAND 8] A 38-year

VRAGEN ADRENAL GLAND
8] A 38-year-old woman is found to have a 3-cm heterogeneous mass in the right adrenal
gland during evaluation for abdominal discomfort. Plasma fractionated metanephrines are
twice the upper limit of normal concentration. A 24-hour urine collection for metanephrines
contains 2.5 times the normal daily excretion. Pheochromocytoma is suspected and
laparoscopic adrenalectomy is planned within the next 14 to 21 days.
The blood pressure is 206/110 mm Hg, and the pulse rate 104/min. She is taking no
medication at this time.
Which of the following would be indicated first before surgery?
A
Carvedilol therapy
B
Blood transfusion
C
Fine-needle aspiration of the mass
D
Phenoxybenzamine therapy
66] A 45-year-old woman with hypertension refractory to therapy with maximal doses of a
diuretic, angiotensin-converting enzyme inhibitor, and calcium channel antagonist is found to
have markedly elevated fractionated plasma metanephrines. A 24-hour urine collection for
metanephrines contains three times the normal daily excretion for a hypertensive patient.
Which of the following is the most appropriate next step in the evaluation of this patient?
A
CT scan of the abdomen, with views of the adrenal glands
B
Plasma catecholamines
C
Glucagon stimulation test
D
MRI of the adrenal glands
E
Met-iodo-benzguanidine (MIBG) scan
80] A 36-year-old man is evaluated in the emergency department for headache and
palpitations. He is anxious, tremulous, and diaphoretic. The blood pressure is 198/106 mm
Hg, and the pulse rate is 110/min. He has been hypertensive for the past 2 years, but has been
suboptimally controlled with a combination of hydrochlorothiazide, diltiazem, and lisinopril.
He frequently experiences similar episodic headache and diaphoresis, during which his blood
pressure is alarmingly high. These episodes had been attributed to migraine headaches, but
addition of propranolol for prophylaxis worsened their frequency and severity.
Which of the following tests would be the most appropriate next step in the management of
this patient?
A
Serum catecholamines
B
Serum potassium
C
Insulin-like growth factor 1
D
Fractionated plasma metanephrines
E
24-hour urine collection for cortisol
74] A 42-year-old man is found to have primary aldosteronism during evaluation of
hypokalemia and hypertension. His plasma aldosterone/plasma renin ratio is 32, with a
plasma aldosterone concentration of 20 ng/dL (554.8 pmol/L). A normal saline infusion test
reveals a plasma aldosterone level of 18 ng/dL (499.32 pmol/L) and a plasma renin activity of
<0.6 ng/h/mL (0.6 µg/h/L).
Selective adrenal venous sampling fails to reveal a gradient between the adrenal glands. The
diagnosis of bilateral adrenal hyperplasia is made, and therapy is initiated with
spironolactone.
The patient's blood pressure normalizes and he discontinues potassium supplementation;
however, he develops painful gynecomastia.
Which of the following is the most appropriate next step in the management of this patient?
A
Substitute lisinopril for spironolactone
B
Karyotype to exclude Klinefelter's syndrome
C
Referral to surgery for bilateral adrenal resection
D
Substitute eplerenone for spironolactone
E
Breast reduction surgery
99] A 48-year-old man is evaluated for possible primary aldosteronism. His plasma
aldosterone/plasma renin activity ratio is 48, with a plasma aldosterone of 24 ng/dL (665.76
pmol/L). A urine collection for aldosterone shows excretion of 26 µg/d (normal <12 µg/d).
CT scan of the adrenal glands shows no abnormality.
Which of the following tests would be the appropriate next step in this patient's evaluation?
A
MRI of the adrenal glands
B
Inferior petrosal sinus sampling
C
Selective adrenal venous sampling
D
Iodocholesterol adrenal imaging
E
Doppler-enhanced ultrasonography of the adrenals
5] A 38-year-old woman is evaluated for a 6-kg (13.2-lb) weight gain over the preceding 2
years. She was also recently found to have a fasting blood glucose of 130 mg/dL (7.22
mmol/L) and 136 mg/dL (7.55 mmol/L) on two separate visits. She is taking no medications
other than a multivitamin and has taken no prescribed medications in the past 5 years.
On physical examination, the patient's BMI is 32 and blood pressure 160/94 mm Hg. The
patient has scant terminal hairs over her chin, mild acne over her face, and violaceous striae,
approximately 1 cm wide, bilaterally over her lateral abdomen. Her face is full, abdomen
prominent, and her arms and legs seem disproportionately thin.
Which of the following is the most appropriate next step in the evaluation of this patient?
A
Serum cortisol, 1600 hrs
B
24-hour urine collection for cortisol
C
Serum cortisol, 0800 hrs, following dexamethasone 8 mg the prior evening
D
Serum ACTH, 0800 hrs
E
MRI of the head
19] A 36-year-old woman is evaluated for weight gain and fatigue. She has gained
approximately 11 kg (22 lb) over the past 18 months and was diagnosed with impaired
glucose tolerance last month. She also has wide violaceous striae. A 24-hour urine collection
shows urine free cortisol of three times the normal upper limit for daily excretion. Serum
ACTH is <5 pg/mL (1.1 pmol/L). CT scan shows a 3-cm right adrenal mass. The left adrenal
gland is very small.
The patient undergoes laparoscopic adrenalectomy and during the first 24 hours after surgery
experiences hypotension and nausea.
Which of the following is the most appropriate management at this time?
A
Surgery to explore for retroperitoneal bleeding
B
Emergent CT scan of abdomen and retroperitoneum
C
Evaluation to insure that the correct adrenal gland was resected
D
Administer hydrocortisone, 100 mg intravenously three times a day
24] A 38-year-old woman is evaluated for suspected Cushing's syndrome. She has central
adiposity, acne, proximal muscle weakness, and hypertension. She consumes at least one
alcohol-containing mixed drink daily and has a recent history of depression. She was recently
diagnosed with type 2 diabetes mellitus, which she controls with diet and exercise. She uses
no medication. On physical examination, she has wide violaceous striae over her flanks and
abdomen.
A 24-hour urine collection for free cortisol contained twice the normal daily amount excreted.
The 0800 hrs serum cortisol measurement, after administration of dexamethasone 1 mg at
2300 hrs the previous evening, is 4 µg /dL (110.36 nmol/L).
Which of the following tests would distinguish pseudo-Cushing's from autonomous
glucocorticoid production in this patient?
A
Cosyntropin stimulation test
B
MRI of the head
C
Measurement of cortisol binding globulin
D
Measurement of serum cortisol, collected at 1600 hrs
E
2-day dexamethasone-corticotropin releasing hormone stimulation test
53] A 40-year-old woman is evaluated for newly diagnosed hypertension and type 2 diabetes
mellitus. She is noted to have central adiposity and wide violaceous striae over her flanks.
Two 24-h urine collections for free cortisol contain four times the normal amount. Serum
ACTH is in the mid-normal range. MRI of the head reveals no pituitary abnormalities.
Dexamethasone 8 mg is given; cortisol only suppresses by 30%. Corticotropin-releasing
hormone stimulation causes a rise in ACTH by 70% and a rise in cortisol by 60%.
Which of the following tests will differentiate the source of ACTH?
A
Inferior petrosal sinus sampling
B
Somatostatin receptor scintigraphy
C
Selective adrenal venous sampling
D
Positron-emission tomography
111] A 28-year-old woman is referred for assistance in diabetes control. Type 2 diabetes
mellitus was diagnosed 2 years ago after a random plasma glucose of 258 mg/dL (14.32
mmol/L) was discovered during evaluation for polyuria and polydipsia. She responded to
metformin therapy, but after 5 months required the addition of glipizide for glycemic control.
She is now being treated with maximal doses of both medications and recently began therapy
with a thiazolidinedione.
The patient is frustrated with her condition. She monitors her capillary blood glucose twice
daily. She walks 30 minutes 5 days a week, but feels too weak to lift weights. She maintains a
carbohydrate-controlled diet, and is neither gaining nor losing weight. She has also had
oligomenorrhea over the past 3 years.
On physical examination, the patient has pendulous breasts, abdominal obesity, and
disproportionately thin arms and legs. Her BMI is 31. She has moderate acne, a ruddy
complexion, and scant terminal hairs on her chin. The hemoglobin A1c is 8.9%.
Which of the following would be the most appropriate next test in the evaluation of this
patient?
A
Insulin-like growth factor 1
B
Thyroid peroxidase antibodies
C
Serum insulin concentration
D
24-hour urine collection for free cortisol
E
Ultrasonography of the ovaries
39] A 56-year-old man is evaluated for anorexia and a 5-kg (11-lb) unintentional weight loss
over the preceding 4 months. He has vague abdominal discomfort and occasional flank pain.
He does not have polyuria, polydipsia, or increased pigmentation.
On physical examination, the BMI is 27 and the blood pressure is 108/72 mm Hg. Aside from
mild tenderness to deep palpation over the left upper abdominal quadrant, the examination is
unremarkable.
CT scan of the abdomen shows a 6-cm left adrenal mass. Attenuation value of the mass is 32
Hounsfield units. The margins of the lesion are irregular and the consistency is heterogeneous.
Radiographic evaluation of the lungs and kidneys reveals no other abnormality.
Plasma fractionated metanephrines are normal. Plasma aldosterone/plasma renin activity
(ARR) is 6 (normal <12). Serum cortisol at 0800 hrs after dexamethasone 1 mg the preceding
evening is 1.4 µg/dL (38.63 nmol/L).
Which of the following is the most appropriate next step in the management of this patient?
A
Selective adrenal venous sampling
B
Repeat biochemical evaluation and CT in 6 months
C
Iodocholesterol imaging of the adrenals
D
Referral for surgical resection of mass
113] A 48-year-old man is diagnosed with a single, surgically accessible focus of non-small
cell carcinoma of the lung. He is undergoing evaluation before possible resection of his
primary tumor. During CT of the chest and abdomen, a 1.5-cm mass is detected in the adrenal
gland contralateral to his lung tumor. The mass is homogenous, has smooth margins, and has
attenuation value of 0 Hounsfield units.
The patient is normotensive and has no electrolyte abnormalities or signs of glucocorticoid
excess.
Which of the following would be the most appropriate next step in the management of this
patient?
A
Cancel surgical resection due to presence of metastatic disease
B
Order fractionated plasma metanephrines, overnight dexamethasone
suppression test, and plasma aldosterone/plasma renin activity ratio.
C
Order selective adrenal venous sampling
D
Order MRI of the adrenal glands
126] A 26-year-old woman is evaluated in the emergency department for lower
abdominal/pelvic discomfort. The blood pressure during the episode is 160/90 mm Hg, but
she has no history of hypertension. She has been in good health until her present episode,
which started several hours before the visit.
Her BMI is 26, and she has no hirsutism, striae, or central adiposity. Hematologic findings
and plasma glucose and serum electrolytes are normal. During her evaluation, the discomfort
lessens and resolves spontaneously and she is released. CT scan of the abdomen done during
the evaluation shows a 1.8-cm irregularity in the right adrenal gland.
Which of the following would be the most appropriate follow-up of this finding?
A
MRI of the abdomen
B
Observation only
C
Repeat CT scan in 1 to 3 months
D
Screen for pheochromocytoma, Cushing's syndrome, and primary
aldosteronism
91] A 43-year-old man is evaluated for persistent hypertension. At the age of 29 years he was
found to have a blood pressure of 160/100 mm Hg during a routine examination, and he was
initially treated with a β-adrenergic antagonist. Since that time, his blood pressure has
remained increased despite weight loss, compliance with therapy, and abstinence from
alcohol. His current therapy consists of maximal doses of hydrochlorothiazide, atenolol,
lisinopril, and amlodipine.
On physical examination, his BMI is 26 and blood pressure is 156/98 mm Hg. He has no
striae, normal facies, and no acral enlargement. There are no abdominal bruits. The fasting
plasma glucose is 98 mg/dL (5.44 mmol/L), potassium is 3.3 meq/L (3.3 mmol/L), and
creatinine is 1.3 mg/dL (114.95 µmol/L).
Which of the following tests would be most appropriate in this patient?
A
Serum insulin-like growth factor 1
B
24-hour urine for free cortisol
C
Plasma fractionated metanephrines
D
Plasma aldosterone/plasma renin activity ratio
E
Magnetic resonance angiography of the renal arteries
33] A 52-year-old man is evaluated in the hospital for persistent hypotension 24 hours after
minor ankle surgery to repair a fracture. Before the fracture, the patient's only symptoms were
chronic headache, general malaise, and fatigue over the past few months, and he adds on more
detailed questioning that he has had occasional dizziness with standing and a 3-year history of
erectile dysfunction. He had not been taking any prescription medications before his
hospitalization and is currently taking only acetaminophen with codeine for postoperative
pain control. Postoperative laboratory evaluation revealed a serum sodium of 132 meq/L (132
mmol/L), potassium of 4.8 meq/L (4.8 mmol/L), hematocrit of 35%, leukocyte count of
15,000/µL (15 × 109/L), and normal liver function tests. Chest radiograph and
electrocardiography are also normal. Blood cultures drawn 24 hours ago are negative.
On physical examination, he is in mild pain and has a healing ankle incision. He is afebrile;
the blood pressure is 88/56 mm Hg and pulse rate 110/min. He does not have
hyperpigmentation, but there is decreased body hair. Cosyntropin (ACTH) stimulation test
reveals a baseline cortisol of 1 µg/dL (27.59 nmol/L) that increased to 10 µg/dL (275.9
nmol/L) 30 minutes after 250 µg of ACTH.
In addition to measuring ACTH and starting corticosteroid replacement, which of the
following is the most appropriate next step in the management of this patient?
A
Measurement of serum follicle-stimulating hormone and luteinizing hormone
B
MRI of the brain
C
CT scan of the abdomen
D
Empiric intravenous antibiotic therapy
103] A 62-year-old man is evaluated for fatigue. He was treated 4 years ago for a
gonadotropin-producing pituitary macroadenoma with transsphenoidal decompression. The
size of the tumor precluded complete resection, and the patient underwent conventional
fractionated radiation therapy of the pituitary gland.
Postoperatively and at his first annual re-evaluation, the patient had a normal response to
cosyntropin stimulation, normal thyroid-stimulating hormone and thyroxine values, and no
evidence of diabetes insipidus. His libido and sexual performance slowly improved and he
was lost to follow-up.
He now has little appetite, but no nausea or vomiting. His libido is poor and he cannot attain
an erection. He has had a very gradual unintentional 4 kg (9.8 lb) weight loss.
On examination, his BMI is 25 and his blood pressure is 104/70 mm Hg. His complexion is
pale and he is finely wrinkled. He has scant facial and pubic hair.
Which of the following is the most appropriate immediate next step in the evaluation of this
patient?
A
Perform a cosyntropin stimulation test
B
Treat with supplemental testosterone
C
Arrange an urgent MRI of the pituitary
D
Arrange for urgent neurosurgical consultation
128] A 23-year-old woman is evaluated in the emergency department for nausea, anorexia,
dizziness, and diffuse moderate abdominal discomfort. Three weeks ago, she had been
evaluated for fatigue and cold intolerance and was noted to have a firm goiter, with the
thyroid estimated to be twice the size expected in a woman of her build. Thyroid peroxidase
antibodies were positive, and her serum thyroid-stimulating hormone (TSH) level was 20
µU/mL (20 mU/L). Hashimoto's thyroiditis was diagnosed, and therapy with levothyroxine,
100 µg/d, is begun. In addition to her symptoms, she has had a 2-kg (4.5-lb) weight loss. In
the emergency department, the blood pressure is 90/60 mm Hg; the pulse rate 100/min, and
she appears darkly pigmented. Laboratory results include serum sodium 132 meq/L (132
mmol/L), potassium 5.0 meq/L (5.0 mmol/L), TSH 6.0 µU/mL (6.0 mU/L), and thyroxine
(T4) normal.
Which of the following would be the most appropriate next test in the evaluation of this
patient?
A
Triiodothyronine (T3)
B
ACTH, cortisol followed by cosyntropin stimulation
C
Thyroid-stimulating immunoglobulins
D
24-hour urine collection for free cortisol