Question 1
A 45-year-old woman presents to the clinic with a history of persistent hypertension that has
been difficult to control despite the use of multiple antihypertensive medications. Over the past
few months, she has noticed an increase in her muscle weakness and frequent urination. She
has also experienced headaches and fatigue. Her medical history is significant for
hyperlipidemia, which is well controlled with statin therapy, but she has no history of
cardiovascular disease. On physical examination, her blood pressure is 160/95 mmHg, and she
appears mildly hypokalemic with a serum potassium level of 3.0 mEq/L. Other findings include
mild muscle weakness and no signs of fluid retention. Laboratory studies reveal low renin levels
and high aldosterone levels. A CT scan of the abdomen confirms a small, well-defined right
adrenal adenoma.
Based on this patient's clinical presentation and laboratory results, what is the most likely
underlying pathophysiologic cause of her condition?
A. Conn syndrome
B. Cushing's syndrome
C. Renal artery stenosis
D. Pheochromocytoma
E. Hyperthyroidism
Question 2
A 10-year-old boy is brought to the emergency department after two days of fever, lethargy, and
vomiting. His mother reports that he had a sore throat and mild cough one week ago, but these
symptoms seemed to resolve on their own. The patient now appears severely ill, with
hypotension, petechial rash on his legs, and rapid breathing. His temperature is 39°C (102.2°F),
heart rate is 140 bpm, and blood pressure is 80/50 mmHg. On examination, he has signs of
disseminated intravascular coagulation (DIC), with multiple small bruises and pinpoint red spots
on his skin. The rest of the examination reveals no focal findings other than the rash and signs
of shock. Blood tests reveal a low platelet count, elevated prothrombin time (PT), elevated
activated partial thromboplastin time (aPTT), and high creatinine. Blood cultures are obtained,
and the results return positive for Neisseria meningitidis.
What is the most likely diagnosis for this child’s presentation?
A. Bacterial endocarditis
B. Acute viral myocarditis
C. Waterhouse-Friderichsen syndrome
D. Disseminated intravascular coagulation due to trauma
E. Sepsis caused by Streptococcus pneumoniae
Question 3
A 58-year-old woman with a history of rheumatoid arthritis presents for a routine follow-up. She
has been on long-term oral corticosteroid therapy (prednisone 10 mg daily) for the past 5 years
for her rheumatoid arthritis. Recently, she has noticed increasing weight gain, particularly in her
abdomen and face, as well as easy bruising and thin skin. She also complains of increased
fatigue, muscle weakness, and frequent urination. On examination, she has central obesity, a
"moon face", abdominal striae, and proximally-located muscle wasting. Her blood pressure is
160/95 mmHg, and her heart rate is 85 bpm. Laboratory findings reveal the following:
- Serum potassium: 3.1 mEq/L (low)
- Serum glucose: 160 mg/dL (elevated)
- Serum cortisol: 30 µg/dL (elevated)
- Urine cortisol: 50 µg/24h (elevated)
Which of the following is the most likely pathophysiologic cause of this patient's symptoms?
A. Pituitary adenoma causing overproduction of ACTH
B. Adrenal adenoma producing excess cortisol
C. Exogenous administration of corticosteroids leading to suppression of the
hypothalamic-pituitary-adrenal (HPA) axis
D. Increased production of cortisol by the adrenal glands due to chronic stress
E. Paraneoplastic syndrome with ectopic ACTH production from a small-cell lung cancer
Question 4
A 45-year-old woman presents with complaints of weight gain, particularly in her abdomen and
face, along with muscle weakness, easy bruising, and striae on her abdomen and thighs. Over
the past 6 months, she has noticed increased fatigue, headaches, and mood swings. Her
medical history includes hypertension and insulin resistance. On examination, she has central
obesity, moon facies, thin skin, and proximal muscle weakness. Blood pressure is 150/90
mmHg, and laboratory results reveal hyperglycemia (fasting blood glucose of 160 mg/dL), low
potassium (3.2 mEq/L), and elevated cortisol levels. A 24-hour urine free cortisol test confirms
elevated cortisol.
What is the next best step to differentiate between Cushing disease and other causes of
Cushing syndrome?
A. Perform a dexamethasone suppression test
B. Measure ACTH levels
C. Perform an adrenal CT scan
D. Obtain a pituitary MRI
E. Perform a CRH stimulation test
Question 5
A 38-year-old woman presents to the clinic with a 2-week history of fatigue, muscle weakness,
and weight loss. She also reports orthostatic dizziness, especially when standing up, and has
noticed an increase in her skin pigmentation, particularly around her elbows, knuckles, and
mouth. Her medical history includes hypertension, which has been managed with lifestyle
changes. She has no history of significant infections, trauma, or autoimmune diseases, but her
mother has a history of autoimmune thyroiditis. On examination, her blood pressure is 98/60
mmHg (lying) and 88/58 mmHg (standing), with a pulse of 110 bpm. Her skin shows darkened
areas (hyperpigmentation) on the knuckles, elbows, and mouth. Laboratory results reveal
hyponatremia, hyperkalemia, and elevated plasma ACTH. A rapid ACTH stimulation test shows
minimal increase in cortisol levels, suggesting adrenal insufficiency.
What is the most likely underlying etiology of this patient's condition?
A. Adrenal gland atrophy due to chronic steroid use
B. Pituitary tumor causing ACTH deficiency
C. Autoimmune destruction of the adrenal glands (Addison disease)
D. Secondary adrenal insufficiency due to hypothalamic dysfunction
E. Congenital adrenal hyperplasia due to 21-hydroxylase deficiency
Question 6
A 5-day-old girl is admitted to the hospital due to vomiting, lethargy, and poor feeding. Her
parents report that she has not passed a stool in 48 hours and appears to be more irritable than
usual. On physical examination, she has dehydration, hyponatremia (serum sodium 126
mEq/L), and hyperkalemia (serum potassium 6.0 mEq/L). Notably, she has ambiguous genitalia,
with an enlarged clitoris and fused labia, suggesting virilization. Family history reveals that her
mother had similar issues during her childhood, and her maternal aunt also had early-onset
adrenal insufficiency.
Which of the following is the underlying pathophysiologic cause of this patient’s condition?
A. Excess cortisol production due to a pituitary tumor
B. Impaired aldosterone and cortisol synthesis due to 21-hydroxylase deficiency
C. Excessive ACTH production from a pituitary adenoma
D. Impaired sodium retention due to renal tubular dysfunction
E. Excess androgen secretion due to adrenal carcinoma
Question 7
A 45-year-old woman presents to the emergency department with a 2-week history of
intermittent episodes of headache, palpitations, sweating, and tachycardia. These episodes last
for about 30 minutes and are associated with an increase in blood pressure to 180/110 mmHg,
after which her symptoms resolve spontaneously. The patient denies any chest pain, shortness
of breath, or recent trauma. Her past medical history is significant for hypertension for which she
takes lisinopril. On examination, her blood pressure is 160/100 mmHg, and heart rate is 100
bpm. Laboratory findings reveal normal renal function and no electrolyte disturbances. Urine
catecholamine and metanephrine levels are markedly elevated. A CT scan of the abdomen
reveals a well-defined mass on the right adrenal gland.
What is the most likely diagnosis for this patient's symptoms?
A. Primary hyperaldosteronism (Conn syndrome)
B. Pheochromocytoma
C. Acute kidney injury due to renovascular hypertension
D. Cushing syndrome
E. Thyrotoxicosis
Question 8
A 52-year-old woman with a history of episodic hypertension, palpitations, and sweating
presents to the emergency department after undergoing a routine right nephrectomy. She has
had these episodes for the past year, which typically last for 30 minutes and resolve
spontaneously. On the evening after surgery, she experiences a sudden severe hypertensive
crisis, with blood pressure rising to 220/130 mmHg. She complains of headache, tachycardia,
nausea, and chest pain. Despite the use of labetalol, her blood pressure remains difficult to
control. Laboratory tests reveal normal renal function, elevated catecholamines, and
metanephrines in the urine. Imaging studies confirm the presence of a tumor in the adrenal
gland on the right side.
What is the next best step in managing this patient’s condition to prevent further hypertensive
crises?
A. Start intravenous sodium nitroprusside to rapidly control blood pressure
B. Start alpha-blockade with phenoxybenzamine, followed by beta-blockade prior to surgery
C. Administer oral beta-blockers for blood pressure control
D. Initiate hydrocortisone and fludrocortisone to support adrenal function
E. Administer IV fluids and glucocorticoids to support volume status
Question 9
A 32-year-old man presents with episodic hypertension, palpitations, sweating, and headaches.
These episodes last for about 30 minutes and resolve spontaneously. His blood pressure during
these episodes reaches 200/120 mmHg. He has also developed flushing and tremors during the
episodes. On further questioning, he reports that his mother had a similar history of episodic
hypertension and a history of thyroid surgery at a young age. His family history is notable for
several relatives with thyroid cancer. Physical examination reveals a slightly enlarged neck, and
a palpable mass is felt in the anterior neck. Laboratory workup shows elevated urinary
catecholamines and metanephrines. A CT scan of the abdomen reveals a mass in the adrenal
gland.
What genetic test should be performed to confirm the diagnosis in this patient?
A. BRCA1 gene testing
B. RET proto-oncogene mutation analysis
C. VHL gene mutation testing
D. MEN1 gene mutation testing
E. PTEN gene mutation testing