INTERNAL MEDICINE ENDOCRINOLOGY

(All PYQ before 2020 , 4th+6th year)

1- A 50-year old patient with diabetes mellitus and diabetic nephropathy.

All the following are true in this patient except:

A- In the early stages, GFR is increased

B- It is the leading cause of end stage kidney disease

C- Nodular glomeruli-sclerosis indicates advanced stage of nephropathy

D- Normal urine analysis does not exclude the presence of the disease

E- Diabetic retinopathy is always present

Answer: E

2-All the following are features of hyperglycemic hyperosmolar coma except:

A- Anion gap more than 25 mmol/L

B- Serum bicarbonate > 20 mmol/L
C- pH > 7.35
D- Serum osmolality > 320 mOsm/Kg
E- Blood glucose > 600 mg/dL
Answer: A

3-One of the followings regarding hyperosmolar hyperglycemia is false:

+A- Blood pH < 7.3
B- Serum Osmolality > 320
C- Glucose > 600
D- Due to DM type 2

features of hyperosmolar hyperglycemia:

-Plasma glucose level of 600 mg/dL or greater
-Effective serum osmolality of 320 mOsm/kg or greater
-Profound dehydration, up to an average of 9L
-Serum pH greater than 7.30
-Bicarbonate concentration greater than 15 mEq/L
-Small ketonuria and absent-to-low
4- One is wrong about hyperosmolar coma:
a. bicarb >20
b. PH>7.35
c. Gluc >33 mmol
d.+ hyperventilation

5-All the following changes are seen in diabetic retinopathy except:

A- Optic atrophy

B- Micro-aneurysms

C- New blood vessels

D- Hemorrhages

E- Exudates

Answer: A

6-All the following cause of thyrotoxicosis are characterized by increased radioiodine

uptake except:

A- Post-partum thyroiditis

B- Solitary toxic adenoma

C- TSH secreting pituitary tumor

D- Grave’s disease

E- Toxic multinodular goiter

Answer: A

7-Which of the following disorders is not a feature of multipole endocrine neoplasia

(MEN) type-2B?
A- Medullary thyroid carcinoma

B- Pheochromocytoma

C- Multiple mucosal neuromas

D- Hyperprolactinemia

E- Hyperparathyroidism

Answer: D
8-All the following are side effects of steroid therapy except:

A- Hypertension

B- Avascular necrosis

C- Hyperglycemia

D- Osteoporosis

E- Hypercalcemia

Answer: E

9-All the following are true regarding primary hyperparathyroidism except:

A- Associated with MEN type-1 syndrome

B- Nephrocalcinosis

C- Osteitis fibrosa cystica

D- Hyperphosphatemia

E- Short QT interval in ECG

Answer: D , in other Q : High phosphate level is seen

# Primary hyperparathyroidism is usually caused by a tumor within the parathyroid gland.

High serum calcium will cause hypophosphatemia

10- all are true in hyperparathyroidism except:

+a- long QT interval.
b-hypercalcemia
c-hypophostatemia

Note : PTH regulates serum calcium and phosphate levels and also plays a part in bone metabolism.
High levels of PTH cause serum calcium levels to increase ( hypercalcemia ) and serum phosphate levels
to fall ( hypophosphatemia ) , The main ECG abnormality seen with hypercalcaemia is shortening of the
QT interval , not prolongation
11- All of the following are true about primary hyperparathyroidism except:
A. Nephrocalcinosis
B. Osteitis fibrosa cystica
C. Long QT interval
D. Associated with MEN
-It occurs in familial MEN syndromes.
-Osteitis fibrosa results from increased bone resorption bt osteoclasts with fibrous
replacement in the lacunae.
-In nephrocalcinosis, scattered opacities may be visible within the renal outline
-it can lead to short QT interval ..not long

12-All the following are true regarding hyperprolactinemia except:

A- Antipsychotic therapy is a well-known cause

B- Secondary hypothyroidism is a recognized cause

C- Galactorrhea

D- Infertility

E- Irregular menses

Answer: B
13-An increased plasma bicarbonate concentration is likely to occur in which of the
following conditions?

A- Chronic renal insufficiency

B- Primary hyperaldosteronism

C- Advanced cirrhosis

D- Pregnancy

E- Salicylate ingestion

Answer: B

14-All the following are manifestations of diabetic autonomic neuropathy except:

A- Erectile dysfunction

B- Postural hypotension

C- Abducent nerve palsy

D- Gastroparesis

E- Constipation

Answer: C .. Abducent is somatic not autonomic

15-All the following are recognized causes of secondary osteoporosis except:

A- Hyperthyroidism

B- Hypogonadism

C- Addison disease

D- Hyperparathyroidism

E- Anti-epileptic medications

F- Steroid

Answer: C
Note: risk factors of osteoporosis; family history, steroid, hyperthyroidism, alcohol,
tobacco, thin, low testosterone, early menopause, renal or liver failure, inflammatory
bone disease, low calcium

*in other forms the answer was adrenal insufficinsy which is the same ..so be aware 

16-The goals of therapy in advanced and metastatic breast cancer include all the
following except:

A- Prolong time to tumor progression

B- Improve cancer free survival

C- Eradicate all evidence of disease

D- Palliate tumor-related symptoms

E- Improve quality of life

Answer: C

17-The goals of therapy in advanced and metastatic breast cancer include all the
following except: (not sure about this question)

A- Prolong time to tumor progression

B- Improve cancer free survival
C- Eradicate all evidence of disease
D- Palliate tumor-related symptoms
E- Improve quality of life

Answer: C

18- TSH high, T3 normal. All are indications for treatment except
A- Infertility
B- Osteoporosis
C-TSH more than 10
D- AntiTSH antibodies
Answer: B
19- Which one is false about adrenal incidentaloma ?
A- FNA cannot distinguish benign and malignant mass
B- 40% of it are functioning
C- Mostly are adrenal adenoma
D- All are true
Answer: D

) ): !! ‫ المفروض يكون الجواب هو الثاني !!!! منطق لطيف‬, ‫(حسب المالحظة تحت‬
Incidental adrenal mass. It is common for a mass in the adrenal gland to be identified on a
CT or MRI scan of the abdomen that has been performed for another indication. Such
lesions are known as adrenal “incidentalomas”. They are present in up to 10% of adults
and the prevalence increases with age. 85% of adrenal incidentalomas are non-
functioning adrenal adenomas. The remainder includes functional tumours of the adrenal
cortex (secreting cortisol, aldosterone or androgens), haeochromocytomas, primary and
secondary carcinomas, hamartomas and other rare disorders, including granulomatous
infiltrations.

20- Which one are mismatched …

A- VMA - renal cell carcinoma
B- Pure red cell aplasia - thymoma
C-Hypercalcemia - squamous cell carcinoma of lung
D-SIADH - small cell carcinoma of lung
Answer: A

21- Wrong about glucagon like peptide 1 (GLP-1)

A- Half life more than 2 hours (less than 2 minutes)
B- Cause gastric emptying
C-Degraded by dipeptidyl peptidase 4
Answer: A

22- Case of acromegaly.. Which is False?

Answer: low IGF-1

NOTE: The clinical diagnosis must be confirmed by measuring GH levels during an oral
glucose tolerance test and measuring serum IGF-1. In normal subjects, plasma GH
suppresses to below 0.5 μg/L (approximately 2 mU/L).
In acromegaly, GH does not suppress and in about 30% of patients there is a paradoxical
rise; IGF-1 is also elevated. The rest of pituitary function should be investigated as
described in. Prolactin concentrations are elevated in about 30% of patients due to co
secretion of prolactin from the tumor. Additional tests in acromegaly may include
screening for colonic neoplasms with colonoscopy
23-In acromegaly all are true EXCEPT:

A- Low serum insulin like growth factor 1

B- Non Suppressed growth hormone after glucose tolerance test

C- Hyperhidrosis (sweating)

D- Hypertension

E-Impaired glucose tolerance

Answer: A

24- All are true about acromegaly except :

a. Suppressed GH by insulin hypoglycemia test
b. Carpal tunnel syndrome
c. Sweating
Answer: A+) Suppressed GH by insulin hypoglycemia test (Glucose)
Explanation: normally GH secretion is inhibited by high glucose, and GH hardly detectable.
In acromegaly, GH release fails to suppress.

25- In acromegaly all are true EXCEPT:

a) High serum insulin like growth factor 1
+b) Suppressed growth hormone after glucose tolerance test
c) Hyperhidrosis
d) Hypertension
e) Impaired glucose tolerance

20- A case of myxedema crises your first line in management:

A- Thyroxin
B- Glucose
C- Fuid
Answer: A

21- Case of 38 YO lady with attacks of hypoglycemia high insulin, concentrated peptide
C also… next step:
A- CT abd.
B- check level of sulpha
C- check insulin
Answer:
22- 25 y female came to clinic 2 months after delivery complaining of palpitations, heat
intolerance, on neck no mass, no tenderness , scan showed 3% uptake what next?
A- B blocker
B- Methemazole
C- Iodine
Answer:A

Note: Post-partum thyroiditis:- The thyrotoxicosis is mild and treatment with a β-blocker
is usually adequate. Antithyroid drugs are of no benefit because thyroid hormone
synthesis is impaired rather than enhanced.

23- All of the following are true about prolactinomas except:

A. Size can be more than 1 cm
B. Size can be less than 1 cm
C. Medical treatment is superior to surgical
D. +Dopamine antagonists are used in treatment
E. commonly presents in females as galactorrhea and amenorrhea
(we use dopamine agonist, not anagoinst)

24- All of the following can cause hyperprolactinemia EXCEPT:

A. OCP
B. Pregnancy
C. Renal failure
D. +Bromocriptine
Note :Bromocriptine is an ergoline derivative and dopamine agonist that is used in the
treatment of pituitary tumors, Parkinson's disease (PD), hyperprolactinaemia,
neuroleptic malignant syndrome, and type 2 diabetes

25- Graves’ disease can cause all of the following except:

A. Ophthalmopathy
B. Diffuse thyroid enlargement
C. +Decreased uptake on isotope scan
D. Pretibial myxedema
Note : There’s diffuse uptake of isotope in Grave’s disease
26- One is false about insulin hypoglycemia test:
A. It will cause increase in GH secretion
B. +Can be used safely in coronary artery disease patients
C. Normal response: cortisol rising to > 18 microgram/dL
D. It works on the principle of stimulation to diagnose a deficiency
E. It will activate the whole HPA axis

Note: Contraindicated for coronary artery disease (ischemic heart disease) patients

27- One of these is not part of MEN syndromes:

A. Hyperparathyroidism
B. Medullary thyroid cancer
C. +Carcinoid tumor
D. Multiple mucosal neuromas

*MEN 1 (Wermer’s syndrome)

-Primary hyperparathyroidisim
-Pituitary tumors
-Pancreatic neuro-endocrine tumors (insulinoma, gastrinoma)
*MEN 2A (Sipple’s syndrome)
-Primary hyperparathyroidism
-Medullary carcinoma of thyroid
-Phaeochromocytoma
-MEN 2B syndrome (marfanoid habitus, skeletal abnormalities, abnormal
dental enamel, multiple mucosal neuromas)

28- Patient presented with new onset hypertension, on examination Cushingoid

features were present, what’s the best screening test?
A. +Low-dose dexamethasone suppression test
B. Serum cortisol
C. Metyrapone
D. High-dose dexamethasone suppression test

Note: If Cushing’s syndrome is suspected: overnight-low dose dexamethasone

suppression test or 24-hr urinary free cortisol.

29- All are features of primary adrenal insufficiency except:

A. +Hypokalemia
B. Hyponatremia
C. Hyperpigmentation
-There hyperkalemia instead of hypokalemia.
30- All are features of Conn’s syndrome except:
A. Hypokalemia
B. Hypertension
C. +Increased serum renin
-In Conn’s syndrome there’s low rennin and high aldosterone -primary
hyperaldosteronism.

31- All are features of diabetic neuropathy except

A. Erectile dysfunction
B. Third cranial nerve palsy
C. +Bradycardia
D. Charcot’s joint
E. Gastroparesis
Note:-Resting tachycardia, not bradycardia

32-What is wrong about diabetic nephropathy?

a. It is the most common cause of end stage renal disease in adults
b. +Papillary necrosis is the most common finding
c. 95% of patients with DM type I have diabetic retinopathy
d. A normal urinalysis doesn’t exclude diabetic nephropathy
e. GFR is increased in the early stages

-Diabetic nephropathy is the most common cause of end stage renal disease in
adults and found with other microvascular complications.
Nodular diabetic glomerulosclerosis: nodular deposits are characteristic and
glomerulosclerosis worsens as heavy proteinuria develops, until glomeruli are
progressively lost and renal function deteriorates.

33- All of the following are features of polycystic ovarian syndrome except:
A. Amenorrhea
B. +Increased FSH/LH ratio
C. Hirsutism and acne
D. Infertility
**Increased LH/FSH ratio.
Normally this ratio is about 1:1 - meaning the FSH and LH levels in the blood are similar
•FSH and LH are often both in the range of about 4-8 in young fertile women
•In women with polycystic ovaries the LH to FSH ratio is often higher – for example 2:1, or
even 3:1
34-Not feature of prolactinoma:
A. Agalactorrhea
B. + fertility (Prolactinoma cause infertility!!)
C. first line management is dopamine agonist
D. more common in male

35-Which of the following will not lead to sinus tachycardia -hypothyroidism

Treatment of hypercalcemia all of the following except :
-Thiazide diuretics

36- Renin is most likely to be suppressed in:

A. +Conn's disease
B. Cushing syndrome

37- A patient presented with blood pressure of 220/180. He is known to have

pheochromocytoma. What's your initial management:
a. +phenoxybenzamine
b. sodium nitroprusside
c. atenolol

38- One is false about insulin hypoglycemia test:

a. it will cause increase in GH secretion
b. +can be used safely in coronary artery disease patients
c. normal response: cortisol rising to > 18 microgram/dL
d. it works on the principle of stimulation to diagnose a deficiency
e. it will activate the whole HPA axis

39- All of the following may be associated with nephrotic syndrome, except:
a. +hypoaldosteronism
b. hypocalcemia
c. renal tubular acidosis
d. thrombosis
e. renal failure
40- A patient presented with weight loss, diarrhea & decrease in libido. Free T4 = 7
(normal: 10-25), TSH = 0.8 (0.2-6). Best next step:
a. urgent thyroid ultrasound
b. +urgent investigation for pituitary
c. investigate for malabsorption
d. anti TPO antibodies
e. start the patient on L-thyroxine
#Diarrhea can be reported by hypothyroid patients.
41- Regarding pituitary apoplexy, one is false:
a. usually arises from non-functioning pituitary adenomas
b. visual field defects need urgent transphenoidal surgery
c. +corticosteroids usually return to normal after surgery
d. can be diagnosed by CT scan
e. presents with sudden headache and visual field defect
(Pituitary apoplexy is bleeding into or impaired blood supply of the pituitary gland, characterized by a
sudden onset of headache, visual symptoms, altered mental status, and hormonal dysfunction due to
acute hemorrhage or infarction of a pituitary gland. An existing pituitary adenoma is usually present)
42- About adrenal crisis, one is false:
a. establish intravenous access with a large-gauge needle
b. +draw blood for serum electrolytes and glucose and routine measurement of plasma
cortisol and ACTH and wait for laboratory results to confirm diagnosis
c. infuse 2 to 3 L of 154 mmol/L NaCl solution as quickly as possible and monitor for signs
of fluid overload by measuring central or peripheral venous pressure and listening for
pulmonary rales
d. inject intravenous hydrocortisone (100 mg immediately and every 6 hr)
e. use supportive measures as needed

43- A clinical case of an old female who took an overdose of b-blocker and failed to
restore her hemodynamics of low heart rate and low blood pressure despite atropine
infusion. What's your next step in management:
a. +IV glucagon
b. noradrenaline
c. dopamine

44- All of the following about Cushing syndrome are true except:
a. +diurnal variation of cortisol is maintained
b. no suppression of cortisol level after giving dexamethasone
c. ACTH level is variable according to the cause
d. steroids use should always be ruled out

45. False about Cushing:

+ Circadian rhythm preserved.

46- Least likely to be associated with osteomalacia:

a. low calcium
b. low vitamin D
c. elevated PTH
d. elevated alkaline phosphatase
e. +elevated creatinine phosphokinase (CPK)
47- About diabetes insipidus, all are true except:
a. +ADH replacement in peripheral cause would treat the condition
b. ADH replacement in psychogenic cause would treat the condition
c. ADH replacement in central cause would treat the condition
d. water deprivation test is used to differentiate psychogenic cause from other causes

48- All of the following are symptoms of thyrotoxicosis except:

a. palpitations
b. frequent bowel motions
c. heat intolerance
d. irritability & insomnia
e. +improved bone mineralization

49- About diabetes, one of the following is not true:

a. type 1 is mostly immune mediated
b. type 1 involves destruction to beta cells of the pancreas
c. type 2 is mainly insulin resistance
d. +type 1 has more genetic predisposition than type 2
e. in the absence of insulin, tissues continue to move glucose, aminoacids, and lipids into
the blood stream

50- A 26 year old female presented complaining of fatigue and weight gain for the last
4-5 months. She is suspected to have Cushing’s syndrome. What is the best screening
test for this condition?

+a. 24 hour urinary cortisol collection

b. Overnight high dose dexamethasone suppression test
c. ACTH level
d. Metyrapone test

51- Which of the following is the first screening test for Cushing’s syndrome
a. Overnight Low dose dexamethasone suppression test
b. High dose dexamethasone suppression test
c. 24 hour urinary free cortisol

Answer: Overnight low dose dexamethasone suppression test.

Note : first <<< Overnight low dose

- The 48-hour low-dose dexamethasone suppression test is the most reliable
screening test. #kumar 24-hour urinary free cortisol: ‫!!!!! مع ذلك انا اظن ان الجواب هو‬

The 24-hour urine-free cortisol is more accurate and is the gold standard for
Confirming or excluding Cushing’s syndrome. #kaplan

{ ***Plasma ACTH levels are low or undetectable in adrenal gland disease (non-ACTH
dependent) and should lead to adrenal imaging. High or inappropriately normal values
suggest pituitary disease or ectopic production of ACTH.
*** High-dose dexamethasone suppression test. Most patients with pituitary dependent
Cushing’s disease suppresses plasma cortisol by 48 hours.
Failure of suppression suggests an ectopic source of ACTH or an adrenal tumour.} #kumar

52- All can be found in DKA except?

a.+ Hyperchloremia
#features of DKA:
-high concentrations of blood ketones -low serum bicarbonate
-low blood pH -hypokalemia -metabolic acidosis
-low O2 sat. -Hypotension -Large anion gap
53- All of the following can be features of diabetic ketoacidosis except

a. Hyperkalemia
b. Ketone bodies
+c. Normal gap metabolic acidosis
d. Hyperglycemia
e…
(Note: wide gap)

54-All of the following will be a lab finding of DKA except:

A-Low HCO3

B-low PH

C-Wide anion gap

+D-Normal PCO2

E-High O2

Answer: D , pco2 will be low in DKA

55- A 65 year old female who is a known case of primary hypothyroidism on thyroxine
replacement therapy on a dose of 100 mcg/day presents to the clinics for a follow up
visit. She is clinically euthyroid. Her labs show a TSH level of 2 (0.5-4.5 Normal range)
and normal T4 and T3. Which of the following is true about her management
a. The L-thyroxine dose must be increased
b. She needs a radioactive iodine scan to determine her thyroid dosage
c. The L-thyroxine dose must be decreased
+d. The L-thyroxine dose should not be changed
e. The L-thyroxine must be discontinued
!! )‫ليش نغير الجرعة يعني‬.. ‫( (بس األرقام طبيعية و زي الفل‬not sure)
56- Hx of hypothyroidism, on levo 100 mic, TSH 9, T3/T4 normal, no symptoms,
Managemen ?:
a. + increase dose
b. decrease dose
c. normal

57- A hypothyroid patient on levothyroxine 100 microgram daily. On follow up, TSH was
0.2 (normal is 0.4-4.5), T4 and T3 were normal, what should be done next?
A. Increase the dose
B. Stop medication
C. +Decrease the dose
The dose of thyroxine should be adjusted to maintain serum TSH within the reference
range.
D. Continue on same dose

Note: In treating hypothyroidism, assessment of thyroid function should be done to

control the dose of thyroxine for these patients. The first to be normalized is T4 (within
the first 1-2 weeks of treatment), in the next 2- 4 weeks T3 is corrected. And TSH needs
2.5-3 months to be normalized. So don't decrease the dose if T3 and T4 were normalized
after several weeks, wait for the TSH to be corrected too

58- All of the following are observed with /true about Grave’s disease except
a. Pretibial myxedema
+b. Multinodular goiter
c. Exophthalmos
d. It is the most common cause of thyrotoxicosis
e. Treated with radioiodine Ablation

59- The earliest sign of diabetic nephropathy except

a. Elevated creatinine
b. Urinary cast
c. Elevated blood urea
d. Red blood cells in urine analysis
+e. Microalbuminuria
Microalbuminuria:
-pathologically, the first changes of renal abnormalities coincide with the onset
of microalbuminuria
-most reliable indicator of incipient diabetic nephropathy within 1st 10 years of
type 1 diabetes
-less reliable in older patients of type 2 diabetes
#earliest manifestation is microalbuminemia, that’s why we have to do urine test for
microalbuminemia in every clinic visit to monitor kidney function & control disease
progression.

69- Early manifestation of DM nephropathy is:

a. +Microalbuminemia
b. Large kidney
c. Diffuse glomerulonephritis
d. Decreased GFR
e. Increased Creatinine

61- All of the following can cause hyperpigmentation except

+a. Pan hypopituitarism
b. Nelson syndrome
c. Renal failure
d. Primary adrenal insufficiency

e. Hemochromatosis

The cause of hyperpigmentation is increase ACTH concentration but in panhypopitiurism

there is no ACTH.

62- All of the following are criteria for the diagnosis of diabetes mellitus except

a. Random blood glucose more than 200 mg/dl

b. HbA1c more than 6.5%

c. Blood glucose 2 hours after an oral glucose tolerance test more than 200 mg/dl

+d. Fasting blood glucose more than 113 mg/dl

e. Fasting blood glucose more than 126 mg/dl

63- Q About DM all are true except?

A. RBG more than 200 mg/dl on 2 occasions in symptomatic patient is diagnostic

B. HbA1c more than 6.5 is diagnostic
C. FBG more than 126 is diagnostic
D. 2 hrs post ogtt reading more than 140 and less than 199 indicates impaired glucose
tolerance
+E. Fasting more than 115 and less than 126 indicates impaired fasting glycemia

64- All of the following are found in patients with secondary adrenal insufficiency
except

a. Hyperkalemia

b. Hypopigmentation

c. Normal aldosterone level

+d. High ACTH

e. Hyponatremia

65- All of the following conditions can cause hyperprolactinemia except

a. Oral contraceptives

b. Antipsychotic drugs

c. Chronic renal failure

+d. Dopamine agonist

e. Primary hypothyroidism

66- All of the following are manifestations of diabetic neuropathy except

+a. Infertility (not sure)

b. Charcot joint

c. Gastroparesis

d. Nocturnal diarrhea

e. Ocular nerve palsy

-Research shows that diabetes can lead to reduced sperm quality but diabetes as such
does not appear to affect motility of sperm (the ability of the sperm to move towards
the egg) or cause infertility as a result. #the global diabetes community

67-All the following are manifestations of diabetic autonomic neuropathy except:

a. Erectile dysfunction
b. Postural hypotension
+c. 3rd nerve palsy
d. Gastroparesis
e. Constipation
Answer: C ,, note : 3rd nerve is somatic not autonomic

68- What isn't in DM neuropathy:

a. resting tachycardia
b. CN VII palsy
c. Gastroparesis
d. + All are true .

69- PCOS wrong:

a.+ hyperprolactinemia
b. high LH:FSH ration
c. Acne
d. Hirsutism
e. Amenorrhea

Explanation: PCO-secondary oligo or amenorrhea, infertility, obesity,

acne, hirsutism

70- All of these cause hyperpigmentation except

a) Hypopituitarism
b) Primary adrenal insufficiency
c) Nelson syndrome

Answer: A+) Hypopituitarism

71- All are causes for Hyperpigmentation of the skin except:
a. + Secondary Adrenal Insuff.
Explanation: causes of hyperpigmentation;
-History of skin inflammation (post-inflammatory hyperpigmentation)
-Use of certain medications (such as minocycline)
-Endocrine diseases such as Addison's disease.
-Hemochromatosis (iron overload) -Sun exposure.

72- Wrong about prolactinoma:

a. + Surgery is the 1st line of management

73- One is not associated With primary adrenal insufficiency:

a. + hypokalemia
b. increased ACTH
c. hyperpigmentation
Explanation: In primary adrenal insufficiency, there is reduced sodium and increased
potassium due to reduced mineralocorticoid.

74- Features of hyperosmolar hyperglycemia EXCEPT?

a-Plasma glucose level of 600 mg/dL or greater
b-Effective serum osmolality of 320 mOsm/kg or greater
c-Serum pH greater than 7.30
d-Bicarbonate concentration greater than 20 mEq/L
e- + Hyperventilation

75- Wrong about diabetic retinopathy:

a. Microaneurysms
b. Hard exudates
c. Retinal detachment
d. + Choroidal changes

76- One of the followings is wrong about diabetic nephropathy:

a. + Kidney biopsy is always needed for the treatment
Renal biopsy is indicated in diabetic patients with an atypical presentation of renal
disease that could be attributed to other renal entities different from diabetic
nephropathy
77- All of the following are true concerning primary hyperthyroidism except
a Increased T3
b Increased T4
+c Increased TSH
Answer: C- Increased TSH
** primary hyperthyroidism T3 & T4 will be increased, and TSH suppressed. While in
secondary hyperthyroidism T3, T4 and TSH will be increase

78- What is the first to happen in diabetic neuropathy?

a. Loss of vibration
b. Loss of pain sensation
c. Muscle wasting
d. Loss of motor
Answer: A)+ Loss of vibration (Not sure)
At first it starts with tingling and numbness ,then muscle weakness + loss of reflexes ,loss
of sensation of temp + pain
-So I'm not 100% sure about the answer, but at least it's not the other 3 options

79) All of the following doesn’t cause secondary osteoporosis, except:

a. Steroids.
b. Hyperthyroidism.
c. Renal failure.
d. Hypogonadism.
Answer:b+) Hyperthyroidism. (hyperthyroidism is a risk factor of osteoporosis)
A: Bone loss occurs because glucocorticoids impair the body’s ability to absorb and
maintain calcium, interfere with vitamin D metabolism, and reduce the production of
estrogen. Glucocorticoids also stimulate bone-destroying cells and inhibit the formation
of bone rebuilding cells.
B: an excess of thyroid hormone over time can cause bone thinning which leads to
osteoporosis and possible fractures.
D: Estrogen is essential to building and maintaining bone. Decreased levels of estrogen
over time result in decreased bone mineral density.

80- Which of the following isn't a cause of osteoporosis

a. Hypogonadism
b. Hypothyroidism
c. Long term heparin effect
d. Steroid
e. Hyperparathyroidism

Answer: b)+ Hypothyroidism

** increased thyroid hormones means increased bone resorption
Medical conditions resulting in secondary osteoporosis may include:

-Serious kidney failure -Cushing's disease -Liver impairment

-Anorexia nervosa and bulimia -Rheumatoid arthritis
-Malabsorption syndromes such as celiac disease -Multiple sclerosis
-Chronic obstructive pulmonary disease (a condition affecting the airways)
-Scurvy
Secondary osteoporosis can also have hormonal causes:

 Hyperparathyroidism: increased activity of the parathyroid glands

 Hyperthyroidism: an excessive secretion of the thyroid glands
 Diabetes.
 Hypercortisolism: a result of systemic illness or long-term use of oral corticosteroid

81- One is not a secondary cause of osteoporosis:

- + conn's disease
- DM
- cushings
82- What is wrong about hypothyroidism…
a. Bradycardia
b. Slow reflexes
c. Pretibial myxedema
d. ↓ T3 & T4 ,↑ TSH

Answer:c)+ Pretibial myxedema

**by default the myxedema is a sign of hypothyrodism , except for pretibial myxedema
which is a hallmark of Grave's Disease (hyperthyrodism)

83- What isn't found in DKA

a. Hypokalemia
b. Hyperphosohatemia
Answer”b)+ Hyperphosohatemia
Note: Total-body stores of sodium, chloride, phosphorous, and magnesium are reduced in
DKA but are not accurately reflected by their levels in the serum because of dehydration
and hyperglycemia. Total body K also is reduced, but because of acidosis serum K may be
high (hypo or hyperkalemia)

84- Acute complication of diabetes :

a+) DKA
b. impotence
**Acute complications of diabetes: DKA + non ketotic hyperosmolar coma

85. Case : DKA patient , least likely to have :

A. Inappropriate respiratory compensation+
B. Wide anion gap
C. Insulin infusion with metformin
D. Adequate hydration
E. Admitted to ICU

86: Which of the following is not part of DKA treatment:

a-Detection and treatment of precipitating factors
b-Insulin infusion
+c-Insulin & Metformin
d-Adequate hydration
e-Correction of electrolyte disturbances
87-Which of the following is not part of DKA treatment:
A-Detection and treatment of precipitating factors
B-Insulin infusion
+C-Start metformin early as possible
D-Adequate hydration
E-Correction of electrolyte disturbances
Answer: C

88- Hypotension , fever, dysuria, chills and rigors in pt who has 13 Years history of
diabetes is most likely :
a) Urosepsis
b) Urethritis
c) Appendicitis
Answer:a+) Urosepsis **not sure about it

89- 55 Years female with 15 Years history of poorly controlled diabetes " feels full of her
stomach " likely to have :
a+) Autonomic neuropathy
Note: it is gastroparesis

90- All are present in primary hyperaldosteronism (Conn syndrome) except :

a+) hyponatremia
**aldosterone = Na+ .. so it should be hyper not hype
remember that conn's is hyper-aldosterne secretion (reabsorb Na+ , and secrete K+ and
H+, resulting in hypokalemia and metabolic alkalosis)
-Other q form with same answer : True about Conn syndrome except ?

91- What is wrong about Sheehan’s syndrome?

a) Low T3, T4 and TSH.
b) Low LH, FSH and estradiol.
c) Postural hypotension.
d) Abnormal visual field.
e) Amenorrhea.
Answer:D) Abnormal visual field. !!! Other Q : Abnormal vision
92- Which of the following is true about Sheehan syndrome
a. Low T3 and T4 but high TSH
b. Normal vision
c. Low LH and FSH and low estradiol
Answer: Low LH and FSH and low estradiol !!!

- Postpartum pituitary gland necrosis ( Sheehan syndrome ), is hypopituitarism caused

by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth,

Signs and symptoms of Sheehan’s syndrome:

- Difficulty breast-feeding or an inability to breast-feed.
- No menstrual periods (amenorrhea) or infrequent menstruation (oligomenorrhea).
- Loss of pubic or underarm hair.
- Slowed mental function, weight gain and difficulty staying warm as a result of an
underactive thyroid (hypothyroidism).
-Low blood pressure. -Fatigue. -Irregular heartbeat. -Loss of interest in sex.
low levels of TSH, ACTH, FSH, and LH with low levels of T4, cortisol, and estradiol in the
blood.
diplopia and changes of vision field may happen with apoplexy by Pressure on the part of
the optic nerve known as the chiasm, which is located above the gland, leads to loss of
vision on the outer side of the visual field on both sides, (( Pituitary apoplexy is regarded
by some as distinct from Sheehan's syndrome, where the pituitary undergoes infarction
as a result of prolonged very low blood pressure, particularly when caused by bleeding
after childbirth. This condition usually occurs in the absence of a tumor

93- Which of the following is true about Sheehan syndrome

a. Low T3 and T4 but high TSH
b. Normal vision
c. Low LH and FSH and low estradiol
Answer: +Low LH and FSH and low estradiol !!!

94- Regarding Sheehan’s syndrome all can be found except

a.+ High FSH , LH with low estradiol

95- All are features of Sheehan's syndrome except " women developed postpartum
hemorrhage" "
+A) Increase ACTH + decrease corticosteroids .
remember than Sheehan cause PAN hypopituitarism which comes postpartum
96- In Sheehan syndrome all of the following are true EXCEPT:
a) Postural hypotension
+b) High prolactin level
c) Low cortisol and ACTH
d) Secondary amenorrhea
e) Low FSH, LH and low estradiol

97- False about hyperthyroidism :

A+) constipation. **Causes diarrhea

98- Metformin cause all of the following except

a) Lactic acidosis
b+) Severe hypoglycemia
c) Weight loss
d) Decrease hepatic glucose production
e) Enhances muscle glucose uptake
** it doesn't increase insulin secretion so there is no risk of hypoglycemia

99- All of the following are true about Metformin, except:

a) It has a very low incidence of lactic acidosis.
b) Its efficacy is similar to that of Sulfonylureas.
c) It decreases the circulating insulin level.
d) It can cause severe hypoglycemia.
Answer: d+) It can cause severe hypoglycemia.
D: It doesn't increase insulin secretion so there is no risk of hypoglycemia when it is used
in monotherapy.
Metformin: Is the first line of treatment for type 2 DM if diet and life style modification
failed in achieving treatment.
It lowers blood glucose level by inhibiting hepatic gluconeogenesis and increasing
peripheral (muscle) uptake of glucose, thus improving insulin sensitivity and decreasing
insulin resistance.
Its efficacy is similar to that of sulfonylureas.
Metformin decreases the circulating insulin level, thus preventing hypoglycemia and
weight gain.
It has a very low incidence of lactic acidosis. But don’t indicate metformin for patients
with renal or hepatic diseases because increase risk of lactic acidosis in these patients.
Contraindicated in: renal failure, liver failure, congestive heart failure, respiratory failure,
DKA, severe infection/sepsis, contrast dye procedure, alcoholism and in pregnancy.
Adverse effects: lactic acidosis (rare), anorexia, GI discomfort and diarrhea.
Characteristics features: no weight gain, no hyperinsulinemia and no hypoglycemia.
NOTE: Metformin improves the quantity of insulin and improves the uptake of glucose
by the tissue, but it does not increase insulin secretion >>> Therefore they are not
associated with hypoglycemia.
100- All of these about DM are related to type 1 rather than type 2 except
a) Age < 16
b) Autoimmune against B-cells
c+) Strong family history
d) Acute symptoms in short period

**although both have genetic predisposition, but DM2 genetics play a bigger role.

101- A pt complaining of hoarseness of voice and cold intolerance, what's not found in
this pt ?
a+) Sinus tachycardia
b) Galactorrhea
-The case Is a hypothyroidism case so it cause bradycardia

102- Which of the following about thyrotoxicosis is wrong ?

a+) Elevated TSH in primary hyperthyroidism

103- Which of the following regarding cushing's syndrome is wrong

A+) The most common cause is Cushing’s disease
most common cause is the use of oral corticosteroids medications

104- All of these cause persistent hypokalemia and HTN except

a) Liddle's syndrome
+b) Bartter's syndrome
c) Cushing's syndrome
d) Conn's syndrome
Note: Bartter's syndrome: rare inherited disease characterized by a defect in the thick ascending
limb of the loop of Henle,, , in Bartter's there is hypokalemia and hypotension.

105-All of the following are true about Grave’s disease except

A- It is more common in females
B- It is the most common cause of thyrotoxicosis
C- It presents usually as Diffuse multinodular goiter
+D-It will cause decrease intake in radio active iodine
Answer: D
106- All are true about Grave's disease except
a) Most common cause of thyrotoxicosis
b) Tibial myexydema is one of the symptoms
c)+ it's characterized by low radioactive iodine uptake
#grave disease is caused by autoantibodies binding to and activating Gprotein coupled
thyrotropin receptor causing increase in hormone production, thus, increase radioactive
iodine uptake

107- All of the following statements are true regarding thyrotoxicosis EXCEPT:
a) More common in females
b) Eye signs and pretibial myxedema suggest a diagnosis of Graves’ disease
c) Radioactive iodine can be used as first line therapy in management of thyrotoxicosis
d) Graves’ disease is the commonest etiology
+e) In thyrotoxicosis due to thyroiditis radioactive iodine uptake is increased.

Answer: E.
The radioactive iodine uptake test or RAIU test: is a type of scan used in the diagnosis
of thyroid problems, particularly hyperthyroidism. The
normal uptake is between 15 and 25 percent, but this may be forced down if, in the
meantime, the patient has eaten foods high in iodine, such as dairy products and seafood.
Low uptake suggests thyroiditis, high uptake suggests Graves' disease, and unevenness
in uptake suggests the presence of a nodule.

108- a pt presented to you with symptoms & signs of thyrotoxicosis. TSH was low &
T3,T4 were elevated , the thyroid scan showed decreased intake , most likely diagnosis:
a. + Subacute thyroiditis
# Low uptake suggests thyroiditis, high uptake suggests Graves' disease, and unevenness
in uptake suggests the presence of a nodule.

109- What is wrong about thyrotoxicosis?

a) More in females.
b) Graves’ disease is the most common etiology.
+c) Radio-iodine ablation is not the first line therapy.
d) If the cause is thyroiditis, there’s low uptake by isotope scan.

A: all endocrine disorders are more common in females –except for diabetes, it’s equal or
even more prominent in males-.in Graves’ disease (M: F ratio is 10:1).
B: Grave’s disease is the most common cause of thyrotoxicosis (75%).
C: Treatment of thyrotoxicosis:
110- The first line of treatment of a case of hypothyroid coma is
a) Ca Gluconate
b) Hydrocortisone
c) 25% dextrose water
d) Normal saline
Note: Immediate intravenous thyroid hormone replacement while awaiting confirmatory
test results (T4 and TSH), even if the diagnosis of myxedema coma is only probable

111- All used in the Dx of growth hormone deficiency except

a) L-dopa
b) Arginine
c)+ Glucose tolerance test
d) Insulin
#GH deficiency is diagnosed by a low level of serum insulinlike growth factor-1 (IGF-1) in
the presence of deficiency of 3 or more pituitaryhormones.
Patients who have deficiency of 2 or fewer pituitary hormones or
pituitary/hypothalamic disease with low IGF-I levels require stimulation tests to establish
the diagnosis of GH deficiency. The two most commonly used
tests are the insulin tolerance test (ITT) and the combination of growth hormone-
releasing hormone (GHRH) and arginine (GHRH-arginine test). The glucagon stimulation
test is a third option.

#glucose tolerance test is used to diagnose acromegaly

112- What is needed to diagnose DM in asymptomatic patient

A)+ 2 reading of FBS> 125 mg/dl
#diagnosis is made by 3 ways:
-symptoms of hyperglycemia + RBS >200mg/dl or FBS >126mg/dl
-high level of serum glucose on 2 separate occasions ( FBS,RBS or OGTT)
-HbA1c> 6.5%

113- All cause short stature except

a)+ Thyrotoxicosis
b) Cystic fibrosis
d) Turner syndrome
d) Decrease in growth hormone
#cystic fibrosis will cause malabsorbtion & FTT, thus affecting stature.
Turner syndrome is associated with short stature.
Low GH will render the body unable to grow appropriately,thus affecting stature.
114- All are true for turner syndrome except
a) Primary amenorrhea
b) Sexual infantilism
c) Congenital heart disease
d)+ Normal breast development

115- All of the following cause impaired glucose tolerance except

A+) Prolactinoma
#some causes of impaired OGTT:
-Pregnancy -diabetes mellitus -acromegaly
-Conn’s syndromes -Cushing syndromes -thiazide using

116- All of the following are management of thyrotoxic crises following surgery for
Grave's disease except
a. + Salicylate
#management of thyrotoxic crises:
-Supportive measures -Antiadrenergic drugs -Thionamides
-Iodine preparations -Glucocorticoids -Bile acid sequestrants
-Treatment of the underlying condition -Rarely plasmapheresis

117- All are features of primary Addison's disease except

#features of primary Addison disease
-hypoglycemia -eosinophillia
-hyponatremia -lymphocytosis
-hyperkalemia -metabolic acidosis
-hypercalcemia

118- All are features of myxedema coma except

a.+ Hyperglycemia

Note: Clinical manifestations include reduced level of consciousness, sometimes

associated with seizures, as well as the other features of hypothyroidism. Hypothermia,
Hypoventilation, leading to hypoxia and hypercapnia, hypoglycemia and dilutional
hyponatremia

119- All are possible complications of DM type II after 5 years from diagnosis except
a.+ Lower limbs hyperreflexia
120- All the following is true about SIADH except
a) The patient is euvolemic
b) The urine osmolarity > 300 mosmol
c) Water restriction is used in the treatment
d)+ Urine Na < 10 mmol
e) The patient is hypoosmolar

Note: SIADH: -Hypo Na (dilutional).. -Hypotonic plasma.. -Hypertonic urine.. -NO EDEMA,
NORMAL VOLUME (Euvolumic)

121- Female patient, post partum had multiple blood transfusion, couldn't breast
feeding her baby , which is not going with this picture :
a.+ T3,T4 are decreased , TSH is increased
b. Decreased ACTH
c. Hypopigimentation
# sheehan’s syndromes will cause pan hypopituitarism, which will cause low levels of
pituitary hormones (luteinizing hormone, corticotropin, and thyrotropin)

122- All might be helpful in the dx of Cushing syndrome , except :

a. insulin hypoglycemic test

#diagnosis of Cushing syndrome includes:

-Blood cortisol levels -Blood sugar -Saliva cortisol levels
-Dexamethasone suppression test -24-hour urine for cortisol and creatinine
-ACTH level -ACTH stimulation test

123- All are highly suggestive of graves’ disease , except :

- diffuse goiter
- high T3, T4 , low TSH
*Both are true
#features of goiter:
-smooth thyroid enlargement
-high hormone production (t3 & t4) low TSH

124- All are features of secondary hypoadrenalism , except :

a.+ Hyperpigmentation
secondary or tertiary adrenal insufficiency is caused by lack of production of ACTH in the
pituitary or lack of CRH in the hypothalamus, thus there will be no excess production of
melanocyte-stimulating hormone fragment that comes from ACTH.

125- A picture of hypokalemia and high blood pressure

126- All are neuropathic complications of DM except:
A+) amyotrophy

# wrong answer !!
# diabetic neuropathies include:
-symmetric sensory polyneuropathy -mononeuritis multiplex
-amyothrophy -autonomic neuropathy

127- About diabetes insipidus one is false :

a.+ associated with high urine osmolality
# DI is the passage of large volume of dilute urine ( low osmolality) due to impaired water
resorption by kidney, either due to low ADH secretion( cranial DI ) or impaired kidney
response to ADH ( nephrogenic DI )

128- patient with a picture suggestive of DKA , all are true except :
a.+ leukocytosis invariably indicates infection

129- Necrobiosis ( the Q was all are skin manifestation of a certain disease except :

Note: Necrobiosis lipoidica is a necrotising skin condition that usually occurs in patients
with diabetes

130- All cause short stature, except:

a.+ Klinfelter syndrome

131- One of the followings regarding primary adrenal insufficiency is false:

a)+ Metabolic alkalosis
b)+ Hypokalemia
c) Hypotension
d) Hypoglycemia

Note: adrenal insufficiency causes hyperkalemia and metabolic acidosis

132- One of the followings is not a feature of Graves’ disease:
a) AF
b) Ophthalmopathy
c) Pseudoclubbing
d)+ Periorbital myxedema
e) Diffuse goiter
*here its periorbital not peritibial ..be aware

133- One of the followings not caused by myxedema coma:

a)+ Tachycardia
b) Hyponatremia
c) Hypothermia
# Note: Clinical manifestations include reduced level of consciousness, sometimes
associated with seizures, as well as the other features of hypothyroidism. Hypothermia,
Hypoventilation, leading to hypoxia and hypercapnia, hypoglycemia and dilutional
hyponatremia

134- One of the following associations is mismatched:

a)+ Primary hypothyroidism : Decreased TSH
# Primary hypothyroidism is a condition of decreased hormone production by the thyroid
gland. The pituitary gland is normal, thus as a compensatory
mechanism by the body there will be an attempt to increase thyroxine level by increasing
TSH.

135- One of the followings about conns disease is false:

a)+ Increased Renin
b) Hypernatremia
c) Hypokalemia
#conn’s disease ( primary aldosteronism ) will cause excessive aldosterone secretion,
sodium retention, hypokalemia & increase blood pressure, thus increasing renal
perfusion, as a result of that there will be low rennin secretion by the kidney.

136- One of the followings is not a complication of acromegaly:

a)+ Central scotoma
b) Prognathism
c) DM
d) Hypertrichosis
e) Hyperhidrosis
#acromegaly can cause visual disturbance b y means of Compression of the optic chiasm
leading to loss of vision in the outer visual fields(typically bitemporal hemianopia.)
137- One of the followings regarding Addison’s disease is false:
a)+ Decreased ACTH
b) Hyperpigmentation
#features of primary Addison disease
-hypoglycemia – eosinophillia -hyponatremia -lymphocytosis
-hyperkalemia -metabolic acidosis -hypercalcemia –
-hyperpigmentation ( due to high ACTH )

138-- Which one of the following is wrong about Addison disease:

A-Hyperpigmentation
B-High ACTH
Answer: both of them are correct

139--Which of the following is wrong about Addison’s disease?

+low ACTH
-hyperpigmentation
-weight loss

140- One of the followings regarding thyrotoxicosisis false:

a) Radioiodine is first line management in thyrotoxicosis
b+) Lid lag in all patients

141- A case of Cushing, one is wrong

a)+ Osteomalacia
#excessive steroid will cause osteoporosis not osteomalacia

142- Which is the endocrine disease that present with low rennin and hypertension
a)+ Conn's disease

143- Growth hormone increase not associated with is :

a)+ Hypocalcemia
#increase GH is associated with:
-Hyperglycemia –hyperphosphatemia -hypercalcemia -high IGF-1
144- Secondary hypothyroidism not associated with :
a)+ Galactorrhea
# secondary hypothyroidism is a condition in which the activity of the thyroid gland is
decreased, due to failure of the pituitary gland or hypothalamus, usually also decreasing
other hormones secreted by pituitary gland.

145- Not associated with osteomalacia:

a)+ Decrease PTH
Note: Vitamin D deficiency leads to impaired intestinal absorption of calcium, resulting in
decreased serum total and ionized calcium values.This hypocalcemia results in secondary
hyperparathyroidism

146- Diabetic nephropathy:

a)+ Normal urine analysis do not rule out renal nephropathy

147- Neuropathy of diabetic treated by:

a)+ Gabapentin
#treatment of painful diabetic neuropathy in consecutive order :
1-paracetamol 2-tricyclic antidepressant ( amitriptyline)
3-SNRI ( duloxetine) 4-anticonvulsant ( gabapentin or pregabalin)
5-opiates

148- Impaired fasting glycaemia:

a)+ 100-125

149- Which of the following is used to diagnose acromegaly?

a.+ Glucose tolerance test
b.Elevated IGF
c.Insulin induced hypoglycemia
# Diagnosing acromegaly involves 2 key blood tests: a test to check the level of the
insulin-like growth factor-1 (IGF-1) and an oral glucose tolerance test (OGTT).

150- Which one of the following is not found in severe Addison:

a.+ Normal aldosterone level
b.Hyperkalemia , hyponatremia
c.Nausea & vomiting
#addison disease ( hypoadrenalism ), featuring low aldosterone,
hyponatremia & hyperkalemia.
151- Which of the following can cause galactorrhea:
a. + Hypothyroidism
#It can be due to dysregulation of certain hormones or local causes such as excessive
nipple stimulation. Hormonal causes most frequently associated with galactorrhea are
hyperprolactinemia and thyroid conditions with elevated levels of thyroid-stimulating
hormone (TSH) or thyrotropin-releasing hormone (TRH). No obvious cause is found in
about 50% of cases.

152- Which of the following test can be used for screen for Cushing:
a.+ Low dose dexamethasone
b.High dose dexamethasone
c.Random cortisol level
d.Insulin induced hypoglycemia

153- All cause hyperpigmentation EXCEPT :

a.Hemochromatosis
b. + 2ndary adrenal insufficiency

154- One is wrong about hyperosmolar coma:

a. bicarb >20
b. PH>7.35
c. Gluc >33 mmol
d.+ hyperventilation

155- One of the followings is not a risk factor for osteoporosis?

a. Steroids
b. + Obesity

156- Which of the following drugs causes osteoporosis:

a. + Heparin
b. Aspirin

157- What isn't in DM neuropathy:

a. resting tachycardia b. CN VII palsy

c. Gastroparesis d. + All are true.

158- Which of the following is not a manifestation of diabetic autonomic neuropathy?
+a) Wrist drop.
b) Diarrhea.
c) Erectile dysfunction.
d) Postural hypotension.

NOTE: Cardiovascular manifestation: Resting tachycardia, Exercise intolerance,

Orthostatic hypotension and Silent myocardial ischemia.
GI manifestation: Esophageal dysmotility, Gastroparesis diabeticorum, Constipation,
Diarrhea and Fecal incontinence.
Genitourinary manifestation: Neurogenic bladder, Erectile dysfunction, Retrograde
ejaculation and Female sexual dysfunction (e.g., loss of vaginal lubrication).
Metabolic manifestation: Hypoglycemia unawareness and Hypoglycemia-associated
autonomic failure
Sudomotor manifestation: Anhidrosis, Heat intolerance, Gustatory sweating and Dry skin.
Pupillary manifestation: Pupillomotor function impairment (e.g., decreased diameter of
dark-adapted pupil) and Argyll-Robertson pupil.

159- What is wrong about adrenal Cushing syndrome?

a) Causes high ACTH.
b) Cause hypertension.
c) Associated with rapid weight gain.

Answer:a+) Causes high ACTH.

A: The causes of ACTH level is high Pituitary ACTH-producing tumor (Cushing’s Disease) or
Ectopic ACTH-producing tumor.
Signs and symptoms of Cushing syndrome:
1. progressive obesity: Weight gain and fatty tissue deposits particularly around the
midsection and upper back (Central obesity), in the face (moon face), and between the
shoulders (buffalo hump).
2. skin changes: Thinning, fragile skin that bruises easily and Acne.
3. Severe fatigue. 4. Muscle weakness. 5. Depression, anxiety and irritability. 5. Loss of
emotional control. 6. Cognitive difficulties.
7. New or worsened high blood pressure. 8. Headache. 9. Bone loss, leading to fractures
over time. 10. In children, impaired growth.
11. Women with Cushing syndrome may experience: Thicker or more visible body and
facial hair (hirsutism) and Irregular or absent menstrual periods.
12. Men with Cushing syndrome may experience: Decreased libido, Decreased fertility
and Erectile dysfunction.
160- Hyperpigmentation can be caused by all of the following, except:
a) Secondary adrenal insufficiency.
b) Ectopic ACTH secretion.
c) Primary adrenal insufficiency.
d) Insulin resistance.
e) Acanthosis Nigricans
Answer: a+) Secondary adrenal insufficiency.
ACTH is converted to anther enzyme; this enzyme stimulate melanin cell so there will be
hyper pigmentation but in secondary adrenal insufficiency there is no ACTH. in Ectopic
ACTH secretion there is a lot of ACTH so there will be hyperpigmentation. in Primary
adrenal insufficiency no feedback inhibition on pituitary so there will be increase in ACTH
production.

161- Which of the following is not part of the management of DKA:

a) Insulin replacement.
b) Fluid replacement.
c) Electrolyte correction especially Potassium.
d) Rapid correction of metabolic acidosis by bicarbonate.

Answer” d+) Rapid correction of metabolic acidosis by bicarbonate.

D: Rapid and early correction of acidosis with sodium bicarbonate may worsen
hypokalemia and cause paradoxical cellular acidosis.
Management of DKA:
1. Correction of fluid loss with intravenous fluids.
2. Correction of hyperglycemia with insulin.
3. Correction of electrolyte disturbances, especially potassium, to prevent arrhythmias.
4. acidosis correction (give NaHCO3).
5. Treatment of precipitating cause.
NOTE: As a part of the management of DKA we do a rapid correction of ketoacidosis not
metabolic acidosis which occur in the case of renal impairment not in the DKA case.

162- All of the following are possible complications of long standing uncontrolled
diabetes, except:
a) Hypercalcemia.
b) Chronic constipation.
c) Chronic diarrhea.
d) Coronary artery disease.

Answer:a+) Hypercalcemia.
A: It should be hypo- not hyper-calcemia because one of the complications of long
standing uncontrolled diabetes is chronic renal failure in which one of its symptoms is
hypocalcemia.
B+C: neuropathy Damage to the nerves related to digestion can cause problems with
nausea, vomiting, diarrhea or constipation.
D: High blood glucose levels over time can lead to increased deposits of fatty materials on
the insides of the blood vessel walls. These deposits may affect blood flow, increasing the
chance of clogging and hardening of blood vessels (atherosclerosis).
Long-term complications of diabetes:
Cardiovascular disease, neuropathy, nephropathy, retinopathy, Foot damage, Skin
conditions and Hearing impairment (Hearing problems are more common in people with
diabetes).

163- Patient with primary hypothyroidism, TSH=7 (upper limit of normal 4.5) ,
what to do about treatment :
+a. increase the dose
b.decrease the dose

164- Not a diabetic autonomic neuropathy:

+a .impairment of position sensation
b. postural hypotension
c. palpitation

note : diabetic neuropathy has two types autonomic & peripheral ,

Peripheral symptoms: Numbness/tingling in the feet , Cramps , Sensitivity/insensitivity to touch ,

Loss of balance/coordination .
Autonomic neuropathy : Postural hypotension , Resting tachycardia , Loss of sweating ,
Gastrointestinal neuropathy ( Gastroparesis , Diabetic diarrhea ) , Urinary bladder atony , Erectile
dysfunction .

165- What is not found in autonomic neuropathy?

a. postural hypotension
b. resting tachycardia
c. erectile dysfunction
d. gastroparesis
+e. loss of joint position sense
166- Not true about diabetic nephropathy:
+a. retinopathy is a good indicator in type 1
b. increase GFR in 1st stages
c. it's the most common cause if ESRD
#Retinopathy is a good indicator in type II

167- Female patient with hypothyroidism, on thyroxine (dosage was given).. She has
normal T3, T4 and increased TSH .. The right thing to do:
a- increase the dose
b- decrease the dose
c- stop the treatment
d- continue with the same dose
Answer: a&d !!!!!!!

168- A known patient of DM presented to his cardiologist. He was found on examination

to have hypertension. What should be our goal in treatment?
a-Maintaining blood pressure under 110/70
+b- Maintaining blood pressure under 130/90

169- Patient with proximal muscle weakness. What is the least test that aid in
diagnosis?!
A. Thyroid function test.
B. Creatine kinase.
+C. LDH.
D. Serum Vitamin D.
E.Serum B12.

170- which of the following not associated with MEN2

+ insulinoma
Note : MEN2 is found in pancreas tumor which called pheochromocytoma ( tumor in
medulla which lead to increase in steroids ) however insulinoma is tumor in B-cells

171- All are true for Digeorge syndrome EXCEPT:

A. Congenital heart disease.
B. Hypoparathyroidism.
C. + Susceptibility for extracellular bacteria and viruses.
D. Thymus abnormality.
Note: mneumonic for Di George: it is c/o is CATCH
C:cardia ( mostly tetratolgy of fallot
A:abnormal face
T:thymic hypoplasia
C:cleft palate
H:hypothyroidism and hypoparathyrodism = hypocalcemia

-Di George is a syndrome caused by the deletion of a small segment of chromosome 22.
symptoms can vary, they often include congenital heart problems, specific facial features,
frequent infections, developmental delay, learning problems and cleft palate

172- A case about proximal muscle weakness, which of the following tests u don't ask
for?
A. TSH
b. CPK
c.

173-Not found in D.M :

+papilledema
#We find macular edema

174- All are occur in diabetic retinopathy except

a. micro aneurysm

b. exudate hemorrhage

c. + papilledema

175- All of the following are causes of hypertension with hypokalemia except
a. Conn’s syndrome
b. Cushing’s syndrome
c. 17- alpha hydroxylase deficiency
+d. Acromegaly
e. Severe renal artery stenosis
Answer: acromegaly

# primary hyperaldosteronism or Conn's syndrome, is excess production of

the hormone aldosterone by the adrenal glands resulting in low renin levels , low blood
potassium is classically described this is only present in about a quarter of people,,,,
-the treatment is surgery in unilateral causes [adenoma] , aldosterone antagonists
(spironolactone) in bilateral ,,,, familial < 1% of cases (11-beta-hydroxylase deficiency
which is AD ) may use dexamethasone in some cases [type 1] . #wiki

-Cushing's syndrome is caused by either excessive cortisol-like medication such

as prednisone or a tumor that either produces or results in the production of excessive
cortisol by the adrenal glands,,,, Cortisol can also exhibit mineralocorticoid activity in high
concentrations, worsening the hypertension and leading to hypokalemia. #wiki

-Congenital adrenal hyperplasia (CAH) are any of

several autosomal recessive diseases resulting from mutations of genes for enzymes
mediating the biochemical steps of production of mineralocorticoids, glucocorticoids or
sex steroids from cholesterol by the adrenal glands…..symptoms of CAH vary depending
upon the form of CAH and the sex of the patient :
- 21-beta-hydroxylase deficiency [95% of cases] (low mineralocorticoids and high
androgens): Hypotension & Hyperkalemia
- 11-beta-hydroxylase deficiency (both are high): HTN with/without hypokalemia.
- 17-alpha-hydroxylase deficiency (high mineralocorticoids and low androgens): HTN &
Hypokalemia.

- Hypokalemia is an uncommon presentation of renovascular hypertension. Although

renal artery stenosis has been associated with hypokalemia secondary to hyperreninemic
hyperaldosteronism.

176- Which of the following is false about endogenous Cushing’s syndrome

a. Most of them are due to pituitary adenoma
b. High dose dexamethasone suppression test is the best to differentiate between causes
c. Ectopic ACTH production is associated with hyperpigmentation and hypokalemia

-Cases due to a pituitary adenoma are known as Cushing's disease. In general It is the
second most common cause of Cushing's syndrome after medication.
- Cushing's disease due to excess ACTH may also result in hyperpigmentation. This is due
to Melanocyte-Stimulating Hormone production as a byproduct of ACTH synthesis from
Pro-opiomelanocortin (POMC). #wiki
- Cortisol can also exhibit mineralocorticoid activity in high concentrations, worsening the
hypertension and leading to hypokalemia (common in ectopic ACTH secretion). #wiki

Mnemonic for cushing -- "cushingoid": - Cataracts, Ulcers, Skin: striae, thinning,

bruising, Hypertension/ hirsutism/ hyperglycemia, Infections, Necrosis, avascular necrosis
of the femoral head, Glycosuria, Osteoporosis, obesity, Immunosuppression,
and Diabetes.
177- All of the following are present in a patient with hypothyroidism except
a. Bradycardia
b. Hoarseness
+c. Brisk reflexes
d. Weight gain
e. Dry skin
Answer: Brisk reflexes ---- is a sign of hyperthyroidism.
#hypothyroidism signs and symptoms:

178- Which of the following is false about diabetes insipidus

+a. Peripheral diabetes insipidus can be treated by giving desmopressin (vasopressin)
b. Water deprivation test should be stopped if urine osmolality of 600 or more is reached
c. Central diabetes insipidus can be treated by giving vasopressin (desmopressin)
d. Hypercalcemia can produce a picture of diabetes insipidus
179- A 60-year-old women presented with increase in weight, cold intolerance and
constipation. All of the following are expected findings on examination EXCEPT:
a) Hoarse voice
+b) Hyperreflexia
c) Dry scanty hair
d) Puffy face
e) Bradycardia

#Note: All are signs and symptoms of hypothyroidism except hyperreflexia which is for
Hyperthyroidism.

180- All of the following are features of diabetic ketoacidosis EXCEPT:

+a) Hypoventilation
b) Abdominal pain
c) Metabolic acidosis
d) Ketonemia
e) May be the first presentation of type 1 diabetes mellitus
#Note: Hyperventilation not hypoventilation happens with DKA, to compensate with the
metabolic acidosis (by hyperventilation we decrease CO2 level, so increasing the PH of the
blood).

181- All of the following conditions can cause hypertension with hypokalemia EXCPT:
a) Conn’s syndrome
b) Liddle syndrome
c) Severe renal artery stenosis
d) Cushing syndrome
+e) 21-betahyroxylase enzyme deficiency
#Note: 21-betahyroxylase enzyme deficiency cause adrenal hyperplasia, which is a salt
wasting syndrome, leads to HTN, hyponatremia, hyperkalemia.

182- Which of the following is least likely to cause hypercalcemia EXCEPT:

a) Vitamin D intoxication
b) Sarcoidosis
c) Thiazide diuretics
d) Multiple myeloma
+e) End stage renal disease
#Note: All of them cause hypercalcemia; the least one may be the End stage renal
disease.
Other causes of hypercalcemia –to refresh your mind =))
Hyperparathyroidism, MEN Type 1, Breast CA, Lung CA, Bone CA, Sarcoidosis, TB, Milk-
alkali syndrome, Thiazide, Lithium, theophylline.
183- All of the following diseases can lead to elevated blood pressure EXCEPT:
a) Renal artery stenosis
b) Primary hyperaldosteronism
c) Cushing’s syndrome
d) Polycystic kidney disease
+e) Acute pyelonephritis.

184- All of the following cause hyperpigmentation EXCEPT:

a) Primary adrenal insufficiency
b) Nelson syndrome
c) Hemochromatosis
+d) Panhypopituitrism.
e) Ectopic ACTH secretion.

The cause of hyperpigmentation is increase ACTH concentration but in panhypopitiurism

there is no ACTH.
Nelson’s syndrome: is the rapid enlargement of a pre-existing ACTH-secreting pituitary
adenoma.
Haemochromatosis: is characterized by the four main features; cirrhosis of the liver,
diabetes mellitus, increased skin pigmentation and heart failure.

185- Hyperprolactinemia can be caused by all EXCEPT:

+a) Diabetes mellitus
b) Hypothyroidism
c) Antipsychotic medications
d) Renal failure
e) Pituitary tumor
answer:A

186- In secondary adrenal insufficiency all of the following are true EXCEPT:
a) Hyponatremia
b) Postural hypotension
c) Low ACTH
d) Hyperkalemia
+e) Hyperpigmentation

Hyperpigmentation occurs when there is excess ACTH but in secondary adrenal

insufficiency no ACTH secretion from pituitary gland.
other manifestations are due to aldosterone deficiency.
187- A 35-year-old women presents to your clinic with a history of headaches,
weakness, fatigue, and polyuria. Her blood pressure is 210/94 mm Hg. Laboratory tests
reveal the following abnormalities: arterial pH 7.48; sodium; 148mmol/L; potassium;
2.7meq/L; HCO3; 37mmol/L; plasma rennin level low; urine chloride;28 mmol/L.

Which of the following is the most likely diagnosis?

a) Diuretic abuse
b) Type 4 renal tubular acidosis
c) Secondary hyperaldosteronism
+d) Primary hyperaldosteronism
e) Milk-alkali syndrome.

Primary hyperaldosteronism is characterized by hypertension, hypokalemia,

hypernatremia, a low plasma renin level, and an elevated urine chloride level (as are seen
in this patient). Secondary hyperaldosteronism is not usually associated with hypokalemia
or metabolic alkalosis; it is usually associated with a high plasma renin level. Patients who
have been abusing diuretics or who have milk-alkali syndrome often present with the
serum values seen in this patient. However, in such patients, the urine chloride level is
usually low (< 10), and these patients often present with volume depletion, whereas mild
volume expansion is characteristic of primary hyperaldosteronism. Type IV RTA causes a
metabolic acidosis.

188- All of the following statement are true regarding endogenous cushing syndrome
EXCEPT:
+a) Best screening test is large dose overnight dexamethasone suppression test
b) Hypokalemia and hyperpigmentation suggest ectopic ACTH secretion
c) The commonest cause is cushing disease
d) Loss of diurnal variation of cortisol secretion
e) In adrenal cushing ACTH will be suppressed

189- Which of the following is not a common feature of osteomalacia ?

a) Low or normal serum calcium level
b) Elevated PTH
+c) Elevated creatine phosphokinase
d) Elevated alkaline phosphatase
e) Low 25-hydroxy vitamin D level
Answer: C, Osteomalacia can cause secondary hyperparathyroidism
#I don’t know why they put CPK as choice :\
The most common cause of osteomalacia is a deficiency of vitamin D. low Vit D lead to
decrease absorption of Ca++ from gut and reabsorption Ca++ form kidney and this result
in low serum Ca++. due to low serum Ca++ the parathyroid hormone will be elevated and
bone deminralztion starts “increase in ALP” ca level may be corrected due to resorption
from bone.

190- Which of the following is not part of DKA treatment:

A-Detection and treatment of precipitating factors
B-Insulin infusion
+C-Insulin & Metformin
DE-Adequate hydration
-Correction of electrolyte disturbances

191- Diagnosis for DM ...

A. Persistent glycosuria
B. Single 6.6 A1C.
+C. 3 times fasting glucose more than 126 with asymptomatic DM

192- female patient has anorexia and amenorrhea, and she is unable to nurse her baby
,what goes with the dx :
A- normal urine cortisol
B-normal ACTH
C-GH isn't suppressed by glucose tolerance test
+D-hypothyroidism

193- case about acromegaly what management?

194-Which one of the following is wrong about hypocalcemia:

A-Trosseu’s sign
B-Carpopedal spasm
C-Seizures
D-Chvostek sign
+E-Prolonged PR interval
195-41-A female patient recently she started complaining of tender , painful neck mass
.. with heat intolerance which one of the following is the most common diagnosis:

A-Hashimoto thyroiditis

B-Grave’s disease

C-Multi nodular goiter

+E- De Quervain's Thyroiditis

Answer: E

196- A patient presented with an increase of TSH and low T4 which one of the following
is the most likely finding:

A. Hypothyroidism+
B. Thyroiditis

197-All of the following statement are true regarding endogenous cushing syndrome
EXCEPT:

A- Best screening test is low dose overnight dexamethasone suppression test

B- Hypokalemia and hyperpigmentation suggest ectopic ACTH secretion

C- The commonest cause is cushing disease

+D-maintainace of diurnal variation of cortisol secretion

E-In adrenal cushing ACTH will be suppressed

Answer: D

198-most common cause of Endogenous cushing?

A- ectopic acth secretion
B- pituitery adenoma++
199- All features of conns syndrome (i think) except?
A- Low acth
B- hyperkalemia ++
C- primary aldosteronism
D- hypokalemia
E- hypernatremia
F- hypertension

200-Doesn’t cause nephrogenic diabetes insipidus?

A- Hypokalemia

B- Hypercalcemia

C- Amyloidosis

D-Pan hypopituitarism++

E- Lithium

201-Hyperparathyroidism all true except:

A-High ALP

B-Low phosphorus

C-High PTH

D-Secondary osteoporosis

E-Pseudo fracture

## All are correct (not sure)

202- Q About which of these not increase radioactive iodine uptake?

A- toxic adenoma
B- grave disease
C-toxic multinodilar goiter
D- Subacute thyroditis +

203- All causes DM except:

+ Insulinoma

204- False about Acromegaly:

+ Localization before biochemical tests

205- Case: patient presented with Fatigue and weight gain , TSH 20... the most likely
condition is :
+Hypothyroidism.

206- Low T4, low TSH .. diagnosis?

A. Hypothyroidism+
B. Thyroiditis

207- Qs about Adrenal Crisis, the false statement is :

+ you need to wait for lab results for management.

208- False about hyperthyroidism:

+ Normal bone scan

209- False about Cushing:

+ Circadian rhythm preserved.

210- False about CKD :

A. Hypoparathyroidism
B. Hypocalcemia
C. Hyperphosphatemia
d.
Answer: A (not sure)
211- False about Diabetes Insipidus :
+ Nephrogenic type can be corrected by giving ADH.

212- False about DM Nephropathy :

+ Papillary is the most common type.

213- 45 year old woman on steroid she is complaining from dysuria fever and vomiting
for 2 days duration , She is febrile, hypotensive 90/65 and has tachycardia
Labs indicates UTI, hypoglycemia 55 mg/dl and hyponatremia 124 and hyperkalemia
In addition to iv antibiotics and fluid you would give her?

A-Iv Glucose
+B-Iv steroid
C-Iv dobutamine
D-Iv epinephrine
Answer: B (This is a case of adrenal insufficiency).

214-Acromegaly does not cause?

+A- Liver cirrhosis
B- HTN
C- Myopathy
D- Macroglossia
E- Glucose intolerance
Answer: A

215-Carpal tunnel syndrome Is caused by which of the following_

Answer: Hypothyroidism
(sorry couldn’t remember any other choices)

216-Regarding insulinoma, which of the following tests you would order?

A- Insulin tolerance test
B- glucagon something
C- first morning C peptide
+D- supervised fasting
Answer: D
217-In a case of Myositis, which of the following tests is not helpful in diagnosis:
A- Thyroid
+B- Vit B12
C- LDH
D- CPK
E- muscle biopsy
Answer: B

218-Not sign of hypocalcemia:

A- chvostek sign
B- laryngeal spasm
C- seizure
Answer: something else,
can’t remember it :3

219-Pheochromocytoma, 1st drug to give ?

Answer: +phenoxycarbamide

220-Sitagliptin mechanism of action?

+A-DDP4 inhibitor
B- GLP-1 analog
# Sitagliptin works by competitively inhibit the enzyme dipeptidyl peptidase 4 (DPP-4). This enzyme
breaks down the incretins GLP-1 and GIP, gastrointestinal hormones released in response to a meal.[19]
By preventing breakdown of GLP-1 and GIP, they are able to increase the secretion of insulin and
suppress the release of glucagon by the alpha cells of the pancreas. #wiki

221-All are causes of hyperpigmentation except

A- Amiodarone
+B- Hypopituitarism
C- Addison's syndrome
D- Hemochromatosis
E- Cushing syndrome
Answer: B
222- A question about diabetes insipidus, which of the following is wrong?

A- Serum is hyperosmolar
B- Peripheral type can be treated with thiazides
+C- Low serum ADH in peripheral type DI
D- Central type can be treated with desmopressin
E- Water deprivation test can diff between DI and psychogenic thirst
Answer: C

Diabetes Insipidus: lack of ADH production or release or use, depending on type of DI , –

regardless of cause, S&S are the same – polyuria (excessive dilute urination) > 2L/day –
Polydipsia – If left untreated >> changes in LOC, tachycardia, tachypnea, hypotension (shock-
like symptoms), but unlike hypovolemic shock, Can lead to hypernatremia , restlessness,
agitation, decrease deep tendon reflexes, seizures

#Diabetes Insipidus (DI) Main Types:

1- Neurogenic/Central DI : insufficient amounts ADH , synthesis, transportation, release –
hypothalamus doesn’t produce enough ADH or posterior pituitary doesn’t release ADH – Most
frequently seen

– Causes : anything that can affect brain’s ability to release ADH • Congenital • CNS disorders –
tumors (pituitary or brain), infections • Cerebrovascular disease or cerebral trauma • Well recognized
complication of closed head injury • Cerebral surgery near the hypothalamohypophysial tract •
pregnancy

Tt: ADH replacement (synthetic vasopressin analog DDAVP – desmopressin,)

2- Nephrogenic/ peripheral DI : inadequate renal response to ADH – ADH produced normally but
distal tubules & collecting ducts can’t respond to hormone’s signal to reabsorb H2O – ADH levels
normal or high

– Causes : Congenital; genetics; familial • Renal obstruction or damage (pyelonephritis, polycystic

disease, amyloidosis) • Chronic kidney disease or end organ failure • Medications (lithium,
demeclocycline, anesthetic methoxyflurane) that damage renal tubules (reversible) • Severe
electrolyte disturbances • Idiopathic with abrupt onset

Tt: Low salt diet – May respond partially to thiazide diuretics……..

3-Psychogenic DI – uncommon
– Causes : Psychogenic disorders or disorders associated with abnormal thirst
• Eg. Water intoxication disorder which is associated with schizophrenia
=================================================================
Adrenal insufficiency Types:

 Primary adrenal insufficiency is due to impairment of the adrenal glands.

o 80% are due to an autoimmune disease called Addison's disease or autoimmune adrenalitis.
o One subtype is called idiopathic, meaning of unknown cause.
o Other cases are due to congenital adrenal hyperplasia or an adenoma (tumor) of the adrenal gland.
 Secondary adrenal insufficiency is caused by impairment of the pituitary gland or hypothalamus. Its
principal causes include pituitary adenoma (which can suppress production of adrenocorticotropic
hormone (ACTH) and lead to adrenal deficiency unless the endogenous hormones are replaced);
and Sheehan's syndrome, which is associated with impairment of only the pituitary gland.
 Tertiary adrenal insufficiency is due to hypothalamic disease and a decrease in the release
of corticotropin releasing hormone (CRH). Causes can include brain tumors and sudden withdrawal from
long-term exogenous steroid use (which is the most common cause overall).

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DONE BY: AHMAD YAHYA