pituitary
A 55-year-old man is evaluated for a 1-year history of decreased libido, erectile dysfunction, and fatigue.
Medical history is also significant for opioid use disorder treated with methadone.
He takes no other medications.
On physical examination, vital signs are normal. BMI is 25.
The remainder of the examination, including genital and prostate examination, is normal.
A morning testosterone level obtained 4 weeks ago is low.
Pituitary MRI is normal.
Laboratory studies:
Hemoglobin Normal
Prolactin 18 ng/mL (18 ug/L) NORMAL
Testosterone, total (8 AM) (second measurement)
140 ng/dL (4.9 nmol/L) LOW
Which of the following is the most appropriate treatment?
male hypogonadism
testosterone replacement therapy
A 47-year-old man is evaluated in the emergency department after 24 hours of severe headache and change in vision.
He has a history of a nonfunctioning pituitary tumor and hypertension.
His only medication is losartan.
On physical examination, temperature is 37 °C (98.6 °F), blood pressure is 100/68 mm Hg, and pulse rate is 102/min.
Bilateral temporal visual field deficits are present.
The remainder of the physical examination is normal.
Laboratory studies
serum sodium level of 130 mEq/L (130 mmol/L).
Intravenous hydrocortisone is administered.
Which of the following is the most appropriate radiology test to perform next?
pituitary tumor
secondary adrenal insufficiency
pituitary MRI
An 81-year-old man is evaluated for a 3-month history of fatigue, constipation, cognitive symptoms, and cold intolerance. He has gained 4.5 kg (10.0 lb) during the past year.
Medical history is significant for coronary artery disease.
Medications are rosuvastatin, lisinopril, metoprolol, and aspirin.
On physical examination, pulse rate is 54/min. Weight is 65 kg (143.0 lb). The thyroid is firm but not enlarged, the skin is cool and dry, and his hair is coarse. Deep tendon reflexes are delayed.
Laboratory studies show
thyroid-stimulating hormone level of 25 microU/mL (25 mU/L) HIGH
free thyroxine level of 0.5 ng/dL (6.5 pmol/L) LOW
Which of the following is the most appropriate treatment?
T4 25 microg/day
A 68-year-old woman is admitted to the ICU for urosepsis. She has a history of hypothyroidism, but levothyroxine is not found among her home medications supplied by her husband. Current therapy consists of Ringer lactate infusion, norepinephrine, vasopressin, and piperacillin-tazobactam.
On physical examination, temperature is 34.0 °C (93.2 °F), blood pressure is 90/40 mm Hg, pulse rate is 64/min, respiration rate is 8/min, and oxygen saturation & is 90% with the patient breathing ambient air.
The patient has periorbital edema, loss of lateral third of eyebrows, 3+ lower extremity pitting edema, distant heart sounds, and absent deep tendon reflexes. She is lethargic with slow responses to questions.
Laboratory studies:
Sodium 130 mEq/L (130 mmol/L)
Thyroid-stimulating hormone 29 microU/L (29 mU/L) HIGH
Thyroxine, free 0.1 ng/dL (1.3 pmol/L) LOW
Cortisol, serum 21 microg/dL (579.6 nmol/L) NORMAL
Arterial blood gas studies are ordered. Supplemental oxygen is provided.
Which of the following is the most appropriate treatment?
IV T4
A 75-year-old woman is evaluated in follow-up for abnormal thyroid function test results.
The test was obtained to evaluate unexplained weight gain over the previous 6 months.
She reports no additional symptoms such as fatigue, cold intolerance, or constipation.
She has no other medical concerns.
On physical examination, pulse rate is 82/min. BMI is 26.
The thyroid is normal size and without nodules.
Laboratory studies
TSH level of 9 U/mL (9 mU/L) HIGH
free thyroxine level of 1.0 ng/dL (12.9 pmol/L) NORMAL
Which of the following is the most appropriate management?
repeat TFTs in 6-8 weeks
A 32-year-old woman is evaluated for a 3-month history of galactorrhea, fatigue, constipation, and weight gain of 3.6 kg (8.0 |b).
With the onset of galactorrhea, her menstrual periods have become irregular and associated with excessive bleeding.
Her most recent menstrual period was 5 weeks ago.
She has no other medical concerns and takes no medications.
On physical examination, vital signs are normal. BMI is 28.
Spontaneous galactorrhea is present. Visual fields are intact. Deep tendon reflexes are delayed. The remainder of her physical examination is normal.
Human chorionic gonadotropin testing is negative.
Serum prolactin level is 68 ng/mL (68 ug/L) HIGH
Which of the following is the most appropriate management?
non neoplastic hyperprolactinemia
TSH measurement
A 45-year-old woman is evaluated for an incidentally found pituitary tumor. She was recently seen in the emergency department following a motor vehicle accident, where head CT demonstrated an 8-mm pituitary tumor without compression of the optic chiasm.
She has otherwise been well with normal menstrual periods and no symptoms suggesting an endocrine disorder.
She takes no medications.
Vital signs and the remainder of the physical examination are normal.
Laboratory evaluation
normal thyroid-stimulating hormone
normal free thyroxine
normal levels of 8 AM serum cortisol
Which of the following is the most appropriate additional lab test?
assess function or non functional
thyroid ok
adrenal ok
repro ok
PRL and ILGF1
A 23-year-old woman is evaluated for cold intolerance and fatigue for the past month. She has hypothyroidism, which is treated with levothyroxine; the dose has been stable since she was 19 years old.
Her only other medication is an iron supplement that was prescribed to treat iron deficiency anemia 2 months ago. Her last menses was 1 week ago. She takes the iron and levothyroxine in the morning on an empty stomach. She waits 1 hour before eating.
On physical examination, blood pressure is 100/50 mm Hg and pulse rate is 60/min; the remainder of the examination is normal. BMI is 23.
Laboratory studies
thyroid-stimulating hormone (TSH) level of 12 U/mL (12 mU/L) HIGH
Her TSH level taken 1 year ago was 1.2 microU/mL (1.2 mU/L) NORMAL
Which of the following is the most likely diagnosis?
decreased T4 absorption
A 51-year-old woman is evaluated for abnormal thyroid function tests. Thyroid function testing was pursued because she has a family history of Hashimoto thyroiditis. She has no symptoms of thyroid disease. She takes large doses of biotin, exceeding 300 mg/d, for its perceived health benefit, but no other drugs.
On physical examination, vital signs are normal. The thyroid gland is normal size without nodules. The remainder of the physical examination is normal.
Laboratory studies
TSH less than 0.01 MU/L (0.01 mU/L) LOW
free thyroxine level of 2.8 ng/dL (36 pmol/L) HIGH
Which of the following is the most appropriate next step in management?
stop biotin and repeat thyroid tests
A 73-year-old woman is seen during a routine evaluation. She has been taking amiodarone for atrial fibrillation for 1 year with good control until a recurrence 1 week ago. Thyroid function tests were normal before starting amiodarone. She has no history of iodinated contrast use. She is otherwise well and takes no additional medications.
On physical examination, pulse rate is 110/min and irregular; remaining vital signs are normal. Other than an irregular tachycardia, the thyroid and remainder of the examination are normal.
Laboratory studies
TSH level of less than 0.01 MU/mL (0.01 mU/L) LOW
free thyroxine level of 3.5 ng/dL (45.0 pmol/L) HIGH
ECG shows atrial fibrillation.
What is your diagnosis?
amiodarone induced hyperthyroidism
A 73-year-old woman is evaluated in the emergency department after 2 days of weakness, headache, and nausea.
She underwent uncomplicated transsphenoidal resection of a pituitary macroadenoma 6 days ago and was discharged from the hospital 3 days ago.
On physical examination, vital signs are normal. No orthostasis and no neurologic or visual deficits are present. Her mucous membranes are moist.
Laboratory studies
serum sodium level of 128 mEq/L (128 mmol/L) LOW
thyroid-stimulating hormone level of 0.9 microU/mL (0.9 mU/L) NORMAL
free thyroxine level of 1.1 ng/dL (14.2 pmol/L) NORMAL
Before discharge
8 AM serum cortisol level was 15 ug/dL (414 nmol/L) NORMAL
random serum cortisol level taken at 3 PM was 10 mg/dL (276 nmol/L) NORMAL
Which of the following is the most likely diagnosis?
SIADH
A 67-year-old man is evaluated for a 4-week history of headache and fatigue. He has metastatic melanoma and receives nivolumab KEYTRUDA every 2 weeks. The patient has otherwise been well and has no additional symptoms. He takes no other medications.
On physical examination, vital signs are normal. Confrontational visual field testing is normal. No focal neurologic findings are present.
On laboratory evaluation
adrenocorticotropin hormone low
8 AM serum cortisol levels are low.
Chest radiograph is normal.
Which of the following is the most likely diagnosis?
cancer targeted therapy
immunotherapy
mab - target PD1
hypophisitis
A 55-year-old man is evaluated for an incidental thyroid nodule that was discovered after undergoing a low-dose chest CT for lung cancer screening. He is asymptomatic, has no family history of thyroid cancer, and has no history of radiation exposure. He has a 20-pack-year history of smoking and quit 3 years ago. He takes no medications.
On physical examination, vital signs are normal. The thyroid is of normal size, without palpable nodules. No cervical lymphadenopathy is noted. The remainder of the examination is unremarkable.
Thyroid-stimulating hormone (TSH) is normal.
Thyroid ultrasonography reveals an 8-mm hypoechoic solid nodule in the right thyroid lobe with regular margins and without extrathyroidal extension. No associated cervical lymphadenopathy is present.
Which of the following is the most appropriate management?
repeat US 12-24 months
A 58-year-old woman is evaluated for a 1-week history of palpitations and dyspnea. She reports having symptoms of mild exertional dyspnea, episodic palpitations, and fatigue 3 weeks earlier, for which she was evaluated in the emergency department with CT angiography for suspected pulmonary embolism. Results were negative. Her symptoms resolved, but then they reappeared 1 week ago. She otherwise has been well and takes no medications.
On physical examination, blood pressure is 150/80 mm Hg, pulse rate is 102/min and irregularly irregular, and oxygen saturation & is 95% breathing ambient air. Other than tachycardia with an irregular rhythm, cardiopulmonary examination is normal. She has a large multinodular goiter with multiple nodules approximately 2 cm without one dominant nodule.
Laboratory studies
TSH level of less than 0.01 MU/mL (0.01 mU/L) LOW
free thyroxine level of 2.3 ng/dL (30.0 pmol/L) HIGH END OF NORMAL
total triiodothyronine level of 230 ng/dL (3.5 nmol/L) HIGH
ECG shows atrial fibrillation.
Which of the following is the most appropriate initial step in management?
start propranolol and methimazole
A 35-year-old woman is evaluated for a 2-month history of fatigue, cold intolerance, constipation, and menorrhagia. She has no recent history of iodinated contrast or iodine supplementation. She takes no medications.
On physical examination, other than a pulse rate of 56/min, vital signs are normal. BMI is 22.
The thyroid is firm and diffusely enlarged two times the normal size. Also noted are dry cool skin and dry coarse hair. No thyroid nodules are palpated.
Laboratory studies
thyroid-stimulating hormone level of 12 U/mL (12 mU/L) HIGH
Which of the following is the most appropriate next diagnostic test?
measure free T4
A 28-year-old woman is evaluated for a 6-month history of amenorrhea. Medical history is significant for schizophrenia. Her only medication is risperidone.
On physical examination, vital signs are normal. BMI is 28. No breast discharge is evident.
Laboratory studies:
Estradiol 20 pg/mL (73 pmol/L) LOW
Follicle-stimulating hormone 1 mU/mL (1 U/L) LOW
Prolactin 150 ng/mL (150 mg/L) HIGH
Thyroid-stimulating hormone 2.2 MU/mL (2.2 mU/L) NORMAL
Thyroxine, free 1.2 ng/dL (15 pmol/L) NORMAL
MRI reveals a normal pituitary gland.
Consultation with the patient's psychiatrist confirms that risperidone cannot be discontinued.
Which of the following is the most appropriate management?
begin EgPg replacement therapy
A 57-year-old woman is evaluated for enlargement of her hands and feet. Medical history is significant for hypertension.
Her only medication is amlodipine.
On physical examination, vital signs are normal. BMI is 24.
The patient has a wide nose and enlargement of hands and feet. Prognathism is noted.
Which of the following is the most appropriate lab diagnostic test?
acromegaly
ILGF1
A 33-year-old man is evaluated for tremulousness, nausea and vomiting, palpitations, dyspnea on exertion, and a 6.8-kg (15.0-Ib) weight loss during the past month.
His medical history is significant for Graves disease diagnosed 3 months ago that was controlled on methimazole and propranolol.
He stopped taking the methimazole 1 month ago.
On physical examination, temperature is 39.4 °C (103.0 °F), blood pressure is 80/50 mm Hg, pulse rate is 135/min and irregular, respiration rate is 28/min, and oxygen saturation & is 93% breathing ambient air.
Cardiac examination reveals a rapid irregular rhythm, jugular venous distention, and bilateral pulmonary crackles.
TSH less than 0.01 MU/mL (<0.01 mU/L) LOW
free thyroxine (T4) & level is 10.0 ng/dL (129.0 pmol/L) HIGH
Chest radiograph shows pulmonary congestion.
ECG reveals atrial fibrillation.
Which of the following is the most appropriate immediate management?
ICU admission
A 28-year-old woman is evaluated for a 2-month history of sleeplessness. She has had panhypopituitarism since surgery for a craniopharyngioma at age 15 years.
Medical history includes hypoadrenalism, hypogonadism, and hypothyroidism. She is taking estrogen, progesterone, hydrocortisone, and levothyroxine.
On physical examination, vital signs are normal.
A small atrophic thyroid is noted; her hands are warm and dry, and no lower extremity edema or tremor is evident.
A thyroid-stimulating hormone level mistakenly obtained at her last office appointment was less than 0.01 microU/mL (0.01 mU/L) LOW
Which of the following is the most appropriate management?
measure free T4
A 46-year-old man is evaluated for a thyroid nodule discovered 2 years ago. Thyroid ultrasonography performed at that time showed a 2-cm left upper pole isoechoic solid nodule without microcalcification or irregular margin. The sonographic pattern was characterized as low suspicion for malignancy. Fine-needle aspiration biopsy showed benign cytology.
On physical examination, vital signs are normal.
A 2-cm left upper pole thyroid nodule is firm and mobile. No lymphadenopathy is evident.
Laboratory studies
thyroid-stimulating hormone level of 2.0 MU/mL (2.0 mU/L) NORMAL
Which of the following is the most appropriate next step in management?
thyroid US
A 32-year-old woman is evaluated for preconception counseling.
She has a history of Cushing disease treated with transsphenoidal resection and irradiation at age 21 years. Her disease is currently in remission; however, 5 years after treatment, she developed secondary hypothyroidism from the pituitary irradiation.
Medications are levothyroxine and an oral contraceptive pill.
Vital signs and physical examination findings are normal.
Measurements of 8 AM serum cortisol and free urinary cortisol are within the normal range.
Free thyroxine is 1.0 ng/dL (12.9 pmol/L) LOW END OF NORMAL
Which of the following is the most appropriate management?
secondary hypothyroidism
TSH useless to monitor
pregnant
needs free T4 upper normal limit
increase T4 dose
A 60-year-old man is evaluated in the emergency department for a 4-week history of nausea, dizziness, and weakness.
He has a 20-year history of substance use disorder, including use of fentanyl.
On physical examination, blood pressure is 100/65 mm Hg and pulse rate is 110/min; other vital signs are normal. BMI is 23.
He has generalized 4/5 weakness in his extremities.
No hyperpigmentation is present.
Laboratory
serum sodium level of 130 mEq/L (130 mmol/L)
serum potassium level of 3.9 mEq/L (3.9 mmol/L).
Which of the following is the most appropriate diagnostic test to perform next?
OIAI
8 AM serum cortisol and ACTH
A 32-year-old woman is evaluated in the first trimester of pregnancy for a 2-week history of heat intolerance, palpitations, and tremulousness.
Her only medication is folic acid.
On physical examination, pulse rate is 110/min; remaining vital signs are normal. The thyroid is nontender and symmetrically and diffusely enlarged. A fine tremor on the patient's outstretched hands is noted.
Laboratory studies
TSH level of less than 0.01 MU/mL (0.01 mU/L) LOW
free thyroxine level of 5.3 ng/dL (68 pmol/L) HIGH
Which of the following is the most appropriate diagnostic test?
TSI measurement
A 56-year-old man is evaluated in the hospital for abnormal thyroid function studies. He was hospitalized 1 week ago for Escherichia coli urosepsis.
Because of persistent hypothermia and bradycardia, thyroid function tests were obtained.
Current treatment consists of 0.9% saline infusion, norepinephrine, and ceftriaxone.
On physical examination, temperature is 36.5 °C (97.8 °F), blood pressure is 90/50 mm Hg, and pulse rate is 100/min.
The patient has normal deep tendon reflexes, no thyroid goiter and no proptosis are noted, and his skin is cool and dry.
TSH level is 0.11 MU/L (0.11 mU/L) LOW
free thyroxine level is 0.8 ng/dL (10.3 pmol/L) LOW
Which of the following is the most appropriate management?
TFTs after recovery
A 59-year-old man is evaluated for a 3-day history of palpitations and a 2.2-kg (5.0-b) weight loss during the past 3 months.
On physical examination, pulse rate is 105/min. A 3-cm right upper pole thyroid nodule is firm and mobile.
Other than tachycardia, the remainder of the examination is normal.
Laboratory studies
TSH level of less than 0.01 MU/mL (0.01 mU/L) LOW
free thyroxine level of 2.5 ng/dL (32.0 pmol/L) HIGH
ECG shows sinus rhythm. Atenolol is initiated.
Which of the following is the most appropriate diagnostic test?
thyroid scintigraphy with RAIU