ABIM Endocrinology 2 — Questions and Answers
Question 1: A 50-year-old man presents with hypertension, hypokalemia, and metabolic alkalosis. Plasma aldosterone-to-renin ratio is markedly elevated. What is the most appropriate next step?
- Start spironolactone empirically
- CT scan of the adrenal glands (Correct answer)
- Adrenal vein sampling
- 24-hour urine aldosterone
Correct answer: CT scan of the adrenal glands
Once primary aldosteronism is confirmed biochemically, CT scan of the adrenal glands is the first imaging step to identify an adenoma versus bilateral hyperplasia.
Question 2: A 55-year-old woman with Cushing disease undergoes transsphenoidal surgery but has persistent hypercortisolism. What is the next treatment option?
- Repeat transsphenoidal surgery or radiotherapy (Correct answer)
- High-dose dexamethasone suppression
- Cabergoline monotherapy
- Bilateral adrenalectomy as first choice
Correct answer: Repeat transsphenoidal surgery or radiotherapy
For persistent Cushing disease after failed transsphenoidal surgery, repeat surgery or pituitary radiation is the preferred next step before bilateral adrenalectomy.
Question 3: A patient with type 1 diabetes presents with DKA: glucose 520 mg/dL, pH 7.18, bicarbonate 10 mEq/L, potassium 5.8 mEq/L. When should insulin be started?
- Immediately before fluid resuscitation
- After fluid resuscitation and potassium is ≥3.5 mEq/L (Correct answer)
- Only after bicarbonate normalizes
- After blood glucose is below 200 mg/dL
Correct answer: After fluid resuscitation and potassium is ≥3.5 mEq/L
Insulin infusion should not be started until potassium is ≥3.5 mEq/L, because insulin drives potassium intracellularly and can precipitate life-threatening hypokalemia.
Question 4: A 40-year-old man has an incidentally found 2.5 cm adrenal mass. It appears lipid-rich on CT (HU < 10). He is normotensive with normal electrolytes. What should be done?
- Immediate adrenalectomy
- Biochemical evaluation for hormonal hypersecretion (Correct answer)
- Repeat CT in 5 years
- PET scan immediately
Correct answer: Biochemical evaluation for hormonal hypersecretion
All adrenal incidentalomas require biochemical evaluation for pheochromocytoma, subclinical Cushing syndrome, and primary aldosteronism, regardless of imaging characteristics.
Question 5: A patient with Graves disease is planning pregnancy. Which treatment is preferred in the first trimester?
- Methimazole
- Propylthiouracil (PTU) (Correct answer)
- Radioactive iodine
- Total thyroidectomy
Correct answer: Propylthiouracil (PTU)
PTU is preferred over methimazole in the first trimester of pregnancy because methimazole is associated with aplasia cutis and choanal atresia in the fetus.
Question 6: A 65-year-old woman with type 2 diabetes develops peripheral neuropathy with burning pain. Her HbA1c is well controlled at 7.1%. What is the first-line pharmacotherapy for her neuropathic pain?
- Opioid analgesics
- Gabapentin or pregabalin (Correct answer)
- Topical capsaicin alone
- NSAIDs
Correct answer: Gabapentin or pregabalin
Gabapentin, pregabalin, and duloxetine are first-line agents for painful diabetic peripheral neuropathy based on efficacy evidence and guideline recommendations.
ABIM Endocrinology 2
A 50-year-old man presents with hypertension, hypokalemia, and metabolic alkalosis.
Plasma aldosterone-to-renin ratio is markedly elevated.
What is the most appropriate next step?