ITE Endocrinology and Metabolism 3

Question 1

A 48-year-old woman has fatigue, weight gain, constipation, and bradycardia. TSH is 48 mIU/L and free T4 is undetectable. She takes no medications. What is the most appropriate initial treatment?

Accepted Answer

Levothyroxine 25 mcg/day with gradual titration

Answer

In severe hypothyroidism, especially in older adults or those with cardiac risk, levothyroxine should be started at a low dose (25–50 mcg/day) and titrated slowly to avoid precipitating cardiac ischemia or arrhythmia.

Question 2

A 55-year-old man with newly diagnosed type 2 diabetes has an HbA1c of 7.8%, BMI 36 kg/m², no cardiovascular disease, and normal renal function. What is the most appropriate pharmacotherapy beyond lifestyle modification?

Accepted Answer

Metformin + GLP-1 receptor agonist

Answer

Current ADA guidelines favor early combination therapy in patients with HbA1c >1.5–2% above goal; adding a GLP-1 agonist to metformin also promotes weight loss, which is beneficial in this obese patient.

Question 3

A 38-year-old woman presents with hypertension, hypokalemia, and metabolic alkalosis. Plasma aldosterone-to-renin ratio is markedly elevated. CT abdomen shows a 1.8 cm right adrenal adenoma. What is the definitive treatment?

Accepted Answer

Laparoscopic right adrenalectomy

Answer

A unilateral aldosterone-producing adenoma confirmed by adrenal vein sampling is best treated with laparoscopic unilateral adrenalectomy, which is curative in most cases.

Question 4

A 32-year-old pregnant woman (20 weeks) is diagnosed with Graves' disease. TSH is suppressed, free T4 is 3.4 ng/dL. Which antithyroid drug is preferred during the second trimester?

Accepted Answer

Methimazole

Answer

Methimazole is preferred after the first trimester; PTU is preferred in the first trimester due to methimazole's teratogenicity risk early in pregnancy, and RAI is absolutely contraindicated in pregnancy.

Question 5

A 62-year-old man with known acromegaly has a post-surgical IGF-1 still 2.5× the upper limit of normal. MRI shows no residual tumor. What is the most appropriate next step in management?

Accepted Answer

Somatostatin receptor ligand (octreotide LAR or lanreotide)

Answer

When post-surgical IGF-1 remains elevated without visible residual tumor, somatostatin receptor ligands are first-line medical therapy; pegvisomant is reserved for those not responding to or intolerant of somatostatin analogues.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE Endocrinology and Metabolism 3