a = new Array(241);
var f = "<FONT FACE=ARIAL SIZE=2>"
a[0] = ""
a[1] = f + "(A) Incorrect. A pituitary adenoma secreting ACTH is less common than a prolactinoma, and would not be associated with amenorrhea-galactorrhea."
a[2] = f + "(B) Incorrect. She does not have findings of acromegaly, which in adults is exhibited by increased soft tissue and joint problems."
a[3] = f + "(C) Incorrect. Paget disease of bone would rarely involve the sella turcica, and would not produce amenorrhea-galactorrhea."
a[4] = f + "(D) CORRECT. The most common mass lesion of the pituitary in the adult is an adenoma that secretes prolactin, and this explains the amenorrhea-galactorrhea that she has been experiencing. A large sellar mass can compress the optic chiasm to produce bitemporal hemianopsia."
a[5] = f + "(E) Incorrect. Hyponatremia can be a consequence of the syndrome of inappropriate ADH, which most often occurs as a consequence of a paraneoplastic process, not a CNS lesion."
a[5.1] = f + "(F) Incorrect. The glucose tolerance test, not frequently done, is most often useful to diagnose hyperglycemia in diabetes mellitus. It may also help in identifying reactive hypoglycemia."
a[5.2] = f + "(G) Incorrect. A decreased TSH from pituitary failure will lead to hypothyroidism."
a[6] = f + "(A) Incorrect. Some of her symptoms such as hypertension, could be consistent with an excess of catecholamines, not a decrease."
a[7] = f + "(B) Incorrect. The iodine uptake is increased with the hyperfunctioning thyroid of Graves disease."
a[8] = f + "(C) Incorrect. She has findings that suggest hyperthyroidism, not diabetes mellitus."
a[9] = f + "(D) CORRECT. There are both thyroid-stimulating immunoglobulins (TSI) and thyroid growth-stimulating immunoglobulins (TGI) in Graves disease that produce hyperthyroidism. The amount of thyroid hormone production goes up, suppressing TSH secretion from the pituitary."
a[10] = f + "(E) Incorrect. Her symptoms are not related to Cushing syndrome or Cushing disease, but to Graves disease."
a[10.1] = f + "(F) Incorrect. Calcitonin may be increased with medullary thyroid cancers, but is not with Graves disease."
a[11] = f + "(A) Incorrect. This is the most common cause for primary adrenocortical insufficiency, but it is not a problem that manifests acutely."
a[12] = f + "(B) Incorrect. This used to be the most common cause of adrenal insufficiency. It is not an acute event."
a[13] = f + "(C) Incorrect. Amyloidosis does not develop acutely."
a[14] = f + "(D) Incorrect. The pituitary necrosis may lead to secondary adrenal insufficiency."
a[15] = f + "(E) CORRECT. This is acute adrenal insufficiency marked by hyponatremia, hyperkalemia, and hypoglycemia. Infection with <I>Neisseria meningitidis</I> can produce the Waterhouse-Friderischsen syndrome."
a[15.1] = f + "(F) Incorrect. Hemochromatosis may produce enough iron deposition in the adrenal to cause chronic Addison disease, but this process takes years. A rare congenital anemia requiring repeated transfusions could produce this finding at this age."
a[16] = f + "(A) Incorrect. Anaplastic thyroid carcinoma is a rare, aggressive neoplasm. This would not explain her hypercalcemia or hypertension."
a[17] = f + "(B) CORRECT. She has MEN IIa, with medullary thyroid carcinomas (often multiple when familial), parathyroid hyperplasia, and pheochromocytoma."
a[18] = f + "(C) Incorrect. Papillary carcinomas do not have amyloid stroma nor calcitonin positivity and do not lead to hypercalcemia or hypertension."
a[19] = f + "(D) Incorrect. Metastases should not be operated. These are not histologic features of renal cell (clear cell) carcinomas, though some renal cell carcinomas are accompanied by hypertension."
a[20] = f + "(E) Incorrect. Hypercalcemia and hypertension could complicate parathyroid carcinomas, but these are not histologic features of such a lesion."
a[20.1] = f + "(F) Incorrect. Follicular carcinomas are not calcitonin positive and are not associated with MEN."
a[21] = f + "(A) Incorrect. A positive anti-TPO suggests an autoimmune process such as Hashimoto thyroiditis."
a[22] = f + "(B) CORRECT. He most likely has a parathyroid adenoma secreting excessive parathormone to increase serum calcium and decrease serum phosphorus. The hypercalcemia leads to increased gastrin production and peptic ulcer disease. Hypercalcemia produces cardiac arrhythmias (or asystole)."
a[23] = f + "(C) Incorrect. Elevated glucose can be seen with Cushing syndrome or diabetes mellitus."
a[24] = f + "(D) Incorrect. Graves disease can be associated with a thyroxine level this high."
a[25] = f + "(E) Incorrect. Pituitary adenomas secreting ACTH (or an ectopic source of ACTH) to produce adrenal hyperplasia, or adrenal neoplasms, can cause secretion of excessive cortisol."
a[25.1] = f + "(F) Incorrect. Increased urinary catecholamines are seen with pheochromocytoma, which can be associated with hypertension but not gastric ulcerations."
a[25.2] = f + "(G) Incorrect. Hyperreninemia may be seen with some forms of renovascular hypertension and with hyperaldosteronism with hypokalemia."
a[26] = f + "(A) CORRECT. This is the most frequent cause for the syndrome of inappropriate ADH (SIADH) leading to her pronounced hyponatremia from lack of free water clearance. Paraneoplastic syndromes are often seen with oat cell carcinomas of the lung."
a[27] = f + "(B) Incorrect. Such trauma could damage the hypothalamic-pituitary axis enough to lead to diabetes insipidus from lack of ADH secretion, not excessive ADH secretion."
a[28] = f + "(C) Incorrect. Lesions of the hypothalamus are uncommon, and destruction of this region by a glioma would result in loss of ADH with diabetes insipidus."
a[29] = f + "(D) Incorrect. Meningitis might produce enough inflammation to interfere with ADH secretion and cause diabetes insipidus, not excess secretion of ADH."
a[30] = f + "(E) Incorrect. Such a neoplasm could theoretically result in diabetes insipidus from a LACK of antidiuretic hormone."
a[31] = f + "(A) Incorrect. The adrenal hemorrhages could explain acute adrenal insufficiency with the laboratory findings given, but not the amenorrhea or failure of lactation or features of hypothyroidism."
a[32] = f + "(B) CORRECT. She has Sheehan syndrome from post-partum anterior pituitary necrosis, leading to loss of pituitary hormones, including gonadotrophic hormone deficiency. The pituitary enlarges in pregnancy, which makes its blood supply more tenuous, and the pituitary is more susceptible to necrosis from events that lead to hypotension."
a[33] = f + "(C) Incorrect. A thyroiditis could lead to hypothyroidism, but this does not explain her adrenal insufficiency."
a[34] = f + "(D) Incorrect. A choriocarcinoma could possibly occur following a normal pregnancy, but metastases are typically to the lungs. Metastases involving the pituitary are quite rare."
a[35] = f + "(E) Incorrect. Insulitis is a pre-clinical finding for type I diabetes mellitus. This does not explain panhypopituitarism. The maternal pancreas is not affected by pregnancy."
a[36] = f + "(A) Incorrect. Such an adenoma could secrete aldosterone, leading to hyokalemia, or cortisol, leading to Cushing syndrome."
a[37] = f + "(B) Incorrect. Medullary carcinomas may secrete calcitonin, which has no major effect upon calcium metabolism."
a[38] = f + "(C) Incorrect. Pheochromocytomas secrete catecholamines, which do not affect calcium metabolism."
a[39] = f + "(D) CORRECT. He has secondary hyperparathyroidism from chronic renal failure. Renal failure with retention of phosphorus drives the calcium down and parathormone secretion up, leading to osteitis fibrosa cystica and bone pain."
a[40] = f + "(E) Incorrect. A pituitary adenoma could produce growth hormone which could lead to acromegaly, in which soft tissue size increases in adults."
a[41] = f + "(A) Incorrect. Subacute granulomatous thyroiditis (DeQuervain disease) leads to transient thyroid enlargement with pain, but the course runs for a month or two and patients typically do not become hypothyroid."
a[42] = f + "(B) Incorrect. Carcinomas of the thyroid are not typically associated with autoantibodies."
a[43] = f + "(C) CORRECT. Hashimoto thyroiditis is the most common cause for hypothyroidism in adults. Though the thyroid may initially have been painlessly enlarged, over time the inflammation leads to atrophy of the thyroid with hypothyroidism. Anti-thyroid autoantibodies are helpful in establishing the diagnosis."
a[44] = f + "(D) Incorrect. A nodular goiter is rather inert, as thyroid lesions go."
a[45] = f + "(E) Incorrect. Graves disease produces hyperthyroidism and thyroid enlargement. Removal of the thyroid as treatment can lead to hypothryoidism."
a[46] = f + "(A) Incorrect. There may be a period of transient hyperthyroidism in this condition."
a[47] = f + "(B) Incorrect. A small number of persons with a multinodular goiter may develop a toxic multinodular goiter with evidence for hyperthyroidism."
a[48] = f + "(C) CORRECT. Medullary carcinomas, derived from interstitial 'C' cells, do not secrete thyroid hormone and are not associated with hyperthyroidism."
a[49] = f + "(D) Incorrect. There may be transient hyperthyroidism in association with Hashimoto thyroiditis early in the course of this disease, but eventually the patient becomes hypothyroid."
a[50] = f + "(E) Incorrect. A small number of follicular adenomas may be 'toxic' adenomas that are 'hot' nodules from increase uptake on scintigraphic scan, and secrete excessive thyroid hormone."
a[51] = f + "(A) CORRECT. She has Cushing syndrome with osteoporosis, hypertension, obesity, and diabetes mellitus. Many adrenal cortical carcinomas function and can produce excess cortisol."
a[52] = f + "(B) Incorrect. Thyroid carcinomas do not explain the finding of diabetes mellitus, though the fracture could have been from a metastasis."
a[53] = f + "(C) Incorrect. Hypopituitarism could result from the empty sella syndrome, but this would not explain hypertension, osteoporosis, and diabetes mellitus."
a[54] = f + "(D) Incorrect. A pheochromocytoma of the adrenal medulla or extra-adrenal paraganglion system secretes norepinephrine or epinephrine that could account for hypertension, but not diabetes mellitus nor osteoporosis."
a[55] = f + "(E) Incorrect. Goiters are not associated with osteoporosis or diabetes mellitus."
a[56] = f + "(A) CORRECT. She has an adrenal cortical adenoma producing excess corticosteroids and leading to Cushing syndrome."
a[57] = f + "(B) Incorrect. A mass at this site suggests an extra-adrenal pheochromocytoma (of the organ of Zuckerkandl)."
a[58] = f + "(C) Incorrect. Ectopic ACTH production from small cell carcinoma with intrapulmonary metastases is possible, but her course would not be this long with such an aggressive neoplasm."
a[59] = f + "(D) Incorrect. Mature cystic teratomas of the ovary rarely contain significant thyroid tissue (struma ovarii). This does not explain the hyperglycemia."
a[60] = f + "(E) Incorrect. Functioning thyroid adenomas are rare. This does not account for hyperglycemia."
a[61] = f + "(A) Incorrect. In Graves disease, there should be an increased amount of thyroid hormone produced, leading to signs and symptoms of hyperthyroidism. The TSH should be low."
a[62] = f + "(B) CORRECT. This combination of tests suggests that there is excess TSH coming from the pituitary, but there is no feedback inhibition, because the thyroxine is also high. This suggests a pituitary adenoma is present. Such a TSH secreting pituitary adenoma is an uncommon cause for hyperthyroidism."
a[63] = f + "(C) Incorrect. The TSH may be low if there is decreased thyroid hormone production from thyroid gland failure, but this would not occur at the same time as an increasted free T4."
a[64] = f + "(D) Incorrect. A thyroidectomy would lead to an increased TSH, but the lack of a thyroid would preclude an elevation in the free T4."
a[65] = f + "(E) Incorrect. Most goiters are associated with a euthyroid state."
a[66] = f + "(A) Incorrect. An elevated cortisol suggests an adrenal adenoma or hyperplasia."
a[67] = f + "(B) Incorrect. The ANA does not often correlate with endocrine diseases."
a[68] = f + "(C) Incorrect. Increased free catecholamines suggests a pheochromocytoma (adrenal or extra-adrenal)."
a[69] = f + "(D) Incorrect. A gastrinoma is typically found in the GI tract or pancreas."
a[70] = f + "(E) CORRECT. She is manifesting the signs and symptoms of hyperthyroidism and probably has Graves disease."
a[71] = f + "(A) Incorrect. There is still an adrenal on the opposite side unaffected by the tumor."
a[72] = f + "(B) Incorrect. The HVA can be increased with neuroblastomas of the adrenal."
a[73] = f + "(C) Incorrect. Adrenal function is not diminished on the opposite side, so ACTH should remain normal."
a[74] = f + "(D) CORRECT. The history is most consistent with a pheochromocytoma of the adrenal medulla (about 10% of pheochromocytomas can be extra-adrenal), which can episodically secrete large amounts of catecholamines. When the surgeon manipulated the mass, catecholamines were released."
a[75] = f + "(E) Incorrect. ANCA's are associated with vasculitis."
a[76] = f + "(A) Incorrect. A papillary carcinoma could produce a 'cold nodule' but would be less common than a follicular adenoma."
a[77] = f + "(B) CORRECT. The majority of 'cold' thyroid nodules are benign and many are adenomas."
a[78] = f + "(C) Incorrect. Such a cyst is more likely to be located in the midline superior to the thyroid."
a[79] = f + "(D) Incorrect. A toxic nodular goiter is an infrequent occurrence, and the whole thyroid would probably be enlarged."
a[80] = f + "(E) Incorrect. DeQuervain disease is very infrequent and would probably not be manifested as a nodule."
a[80.1] = f + "(F) Incorrect. Hashimoto thyroiditis early in its course produces diffuse, painless thyroid enlargement. There may be transient hyperfunction, but eventually atrophy and hypothyroidism occur."
a[81] = f + "(A) Incorrect. Some degree of atypia can be found even in adenomas of endocrine glands, including adrenal cortical adenomas."
a[82] = f + "(B) Incorrect. Mitoses could be found even in adrenal adenomas, though many mitoses (or bizarre mitoses) strongly suggest malignancy."
a[83] = f + "(C) CORRECT. Only a malignant endocrine tumor would invade and/or metastasize. The other features listed are suggestive of malignancy, but are not absolute."
a[84] = f + "(D) Incorrect. The greater the size of an adrenal neoplasm, the greater the likelihood of malignancy."
a[85] = f + "(E) Incorrect. Necrosis suggests malignancy, but is not an absolute indicator."
a[86] = f + "(A) CORRECT. Osteitis fibrosa cystica is a metabolic bone disease that occurs as a complication (one of the causes for bone pain) of primary hyperparathyroidism, which she likely has because her serum calcium is elevated and phosphorus decreased."
a[87] = f + "(B) Incorrect. An osteoid osteoma could produce similar pain, but is not associated with hypercalcemia from hyperparathyroidism."
a[88] = f + "(C) Incorrect. An osteochondroma is typically seen as a lateral projection at the metaphysis of a long bone, and it is not related to hyperparathyroidism."
a[89] = f + "(D) Incorrect. Osteomyelitis may produce focal bone pain, but it is not associated with hyperparathyroidism."
a[90] = f + "(E) Incorrect. Osteoporosis can lead to decreased bone mass, and a fracture in the weakened bone could cause pain, but it is a general, not focal process."
a[90.1] = f + "(F) Incorrect. Osteosarcomas tend to be large invasive masses arising in the metaphyseal regions of long bones in young adults. They are not related to hypercalcemia."
a[91] = f + "(A) Incorrect. A goiter is the most common cause for an enlarged thyroid, but there is no pain and patients are typically euthyroid."
a[92] = f + "(B) Incorrect. Lymphomas of the thyroid are not common, but may arise in the setting of autoimmune disease."
a[93] = f + "(C) CORRECT. Granulomatous thyroiditis tends to be a self-limited disease that runs a course over weeks. Patients may initially be hyperthyroid, then hypothyroid, then euthyroid. Prior viral infection is implicated in some cases."
a[94] = f + "(D) Incorrect. Hashimoto thyroiditis enlarges the thyroid intially, but it is not painful, and the course of the disease runs much longer, over years, with eventual thyroid atrophy and clinical hypothyroidism."
a[95] = f + "(E) Incorrect. The thyroid is enlarged with Graves disease, but patients remain hyperthyroid unless treated."
a[95.1] = f + "(F) Incorrect. Riedel thyroiditis is a very rare idiopathic condition with extensive fibrosis and scarring that mimics a carcinoma grossly."
a[95.2] = f + "(G) Incorrect. Iodine deficiency can lead to a goiter, with painless enlargement. Most patients remain euthyroid."
a[96] = f + "(A) Incorrect. ADH comes from the hypothalamus and is released via the posterior pituitary."
a[97] = f + "(B) CORRECT. More pituitary adenomas secrete prolactin than any other hormone. Also, he did not have symptoms indicative of any other hormonal secretion. In a man, prolactinemia may not have major effects. The adenoma pressing on the optic chiasm is a mass effect that did explain his visual problem"
a[98] = f + "(C) Incorrect. He did not have Cushing disease."
a[99] = f + "(D) Incorrect. He did not have acromegaly."
a[100] = f + "(E) Incorrect. It is rare for a pituitary adenoma to secrete LH."
a[101] = f + "(A) Incorrect. The giant cells are a feature of granulomatous thyroiditis."
a[102] = f + "(B) Incorrect. This is a finding of medullary thyroid carcinoma."
a[103] = f + "(C) Incorrect. Follicles suggest a follicular neoplasm. Most are cold nodules and most are benign."
a[104] = f + "(D) CORRECT. The histologic finding of clear nuclei is the hallmark of a papillary carcinoma, and lymph node is the first site for metastasis."
a[105] = f + "(E) Incorrect. This is more typical for anaplastic carcinoma of thyroid."
a[106] = f + "(A) Incorrect. CAH should produce sexual precocity and hypertension."
a[107] = f + "(B) Incorrect. Adrenal cortical carcinomas are seen in adults and are not associated with HVA or VMA production."
a[108] = f + "(C) CORRECT. The baby has a neuroblastoma, one of the most common childhood tumors. These tumors produce catecholamine precursors such as vanillylmandelic acid (VMA) and homovanillic acid (HVA) in small amounts, so hypertension is unusual."
a[109] = f + "(D) Incorrect. Lymphomas at this age are rare, and they do not have endocrine function."
a[110] = f + "(E) Incorrect. Pheochromocytomas are adult tumors that secrete catecholamines."
a[110.1] = f + "(F) Incorrect. Conn syndrome is most often the result of an aldosterone-secreting adrenal cortical adenoma. This condition occurs in adults."
a[111] = f + "(A) CORRECT. Anaplastic carcinoma of the thyroid is a highly aggressive, infiltrative mass lesion with a poor prognosis. Fortunately, it is rare."
a[112] = f + "(B) Incorrect. Follicular carcinomas tend to be indolent, even if invasive or metastatic."
a[113] = f + "(C) Incorrect. Medullary carcinomas are not this aggressive. They have a RET gene mutation."
a[114] = f + "(D) Incorrect. Non-Hodgkin lymphomas are composed of large lymphoid cells."
a[115] = f + "(E) Incorrect. Papillary carcinoma of the thyroid has the best prognosis. This neoplasm an indolent course."
a[115.1] = f + "(F) Incorrect. This is very aggressive locally and also associated with hypercalcemia."
a[116] = f + "(A) Incorrect. This is a type of congenital adrenal hyperplasia seen in infants."
a[117] = f + "(B) CORRECT. The history points to an aldosterone secreting neoplasm, which is usually a small adenoma within adrenal cortex. This is known as Conn syndrome, one of the surgically treatable causes for hypertension."
a[118] = f + "(C) Incorrect. Pituitary lesions do not secrete aldosterone."
a[119] = f + "(D) Incorrect. This is not a complication of steroids."
a[120] = f + "(E) Incorrect. Renal cell carcinomas are not known for secreting aldosterone."
a[121] = f + "(A) Incorrect. Amyloid stroma is a feature of medullary carcinomas of the thyroid, not Hashimoto thyroiditis. The inflammation with thyroiditis is not prolonged or severe enough to cause systemic amyloidosis."
a[122] = f + "(B) CORRECT. Hypothyroidism can occur years later in the course of Hashimoto thyroiditis. This is the most common cause for hypothyroidism in adults."
a[123] = f + "(C) Incorrect. There is a greater incidence of non-Hodgkin lymphoma in patients with Hashimoto thyroiditis, but this is still uncommon."
a[124] = f + "(D) Incorrect. Papillary carcinoma, and thyroid carcinomas in general, are unrelated to thyroiditis."
a[125] = f + "(E) Incorrect. Riedel thyroiditis is a rare idiopathic condition with extensive fibrosis of the thyroid."
a[126] = f + "(A) Incorrect. Sheehan syndrome is typically a postpartum event."
a[127] = f + "(B) Incorrect. Acute infection with <I>Neisseria meningitidis</I> typically produces this form of acute adrenal failure, and it is associated with fever and disseminated intravascular coagulopathy."
a[128] = f + "(C) CORRECT. The hyponatremia, hyperkalemia, and hypoglycemia are characteristic for acute adrenal failure. She received a normal replacement dose of corticosteroids during her hospitalization, but the stress of surgery and infection increased her need for cortisol. Her chronic corticosteroid therapy resulted in adrenal atrophy, and her own adrenals could not respond to the challenge."
a[129] = f + "(D) Incorrect. An aldosterone secreting adenoma of the adrenal would be associated with hypokalemia."
a[130] = f + "(E) Incorrect. This is a congenital condition."
a[131] = f + "(A) Incorrect. The thyroid may become symmetrically enlarged with Graves disease, but the T4 should be elevated and the TSH depressed."
a[132] = f + "(B) CORRECT. The most common cause for thyroid enlargement is a simple, nodular goiter. Most patients are euthyroid with this condition. Places far away from a seacoast (a source for iodine) are where endemic goiter used to be seen. Use of iodized salt eliminated the problem."
a[133] = f + "(C) Incorrect. Anti-thyroid peroxidase antibodies are typically present with Hashimoto thyroiditis. Over time, the thyroid becomes atrophic."
a[134] = f + "(D) Incorrect. Anaplastic carciomas are rare but highly aggressive neoplasms that invade surrounding structures in the neck."
a[135] = f + "(E) Incorrect. An adenoma is generally no more than 3 cm in size and localized."
a[135.1] = f + "(F) Incorrect. Though papillary carcinoma can be an indolent condition, it continues to enlarge. It is unlikely to cause diffuse enlargement."
a[136] = f + "(A) Incorrect. A prolactinoma arising in the anterior pituitary can become large enough to erode the sella, but it is a solid mass without calcifications."
a[137] = f + "(B) Incorrect. Metastases to this site are quite unusual. Germinomas can arise in the pineal gland nearby."
a[138] = f + "(C) Incorrect. Herniation of the arachnoid through the diaphragma sella can flatten the pituitary and produce hypopituitarism, but the sella is not expanded."
a[139] = f + "(D) Incorrect. Glioblastomas can arise near the base of the brain, but they typically do not erode bone, nor do they contain calcifications."
a[140] = f + "(E) CORRECT. A craniopharyngioma is a rare and sporadic neoplasm of older children and young adults. Craniopharyngiomas produce a mass effect in the region of the sella and can impinge upon the optic chiasm. They have histologically benign appearing tissue, but they erode and invade surrounding bone and can be difficult to remove completely. The term 'crankcase oil' is used to describe the oily contents of a craniopharyngioma. The microscopic features suggest embryologic origin from Rathke's pouch."
a[140.1] = f + "(F) Incorrect. Osteosarcomas, though common at this age, are likely to arise in long bones, not the skull."
a[141] = f + "(A) Incorrect. Pheochromocytomas secrete norepinephrine and epinephrine, not ACTH or cortisol."
a[142] = f + "(B) Incorrect. Follicular carcinomas do not produce ACTH or cortisol."
a[143] = f + "(C) Incorrect. Sarcomas in general do not produce paraneoplastic syndromes."
a[144] = f + "(D) CORRECT. Small cell ('oat cell') carcinomas can secrete a variety of hormone-like substances that produce many types of paraneoplastic syndromes, of which Cushing syndrome from ectopic ACTH secretion is one."
a[145] = f + "(E) Incorrect. Islet cell tumors secrete insulin, glucagon, or gastrin, and rarely secrete ACTH."
a[146] = f + "(A) CORRECT. He has 'central' diabetes insipidus. ADH is made in the hypothalamus and then stored and released from the posterior pituitary. A lack of ADH leads to polydipsia and polyuria from excessive excretion of free water by the kidney, leading to hypernatremia and increased serum osmolality."
a[147] = f + "(B) Incorrect. Oxytocin is stored in the posterior pituitary like ADH and plays a role in milk let-down for lactation."
a[148] = f + "(C) Incorrect. Insulin functions to increase glucose transport into fat, muscle, and connective tissues."
a[149] = f + "(D) Incorrect. GH has an anabolic effect."
a[150] = f + "(E) Incorrect. Prolactin promotes lactation by the breast."
a[151] = f + "(A) Incorrect. The TSH will not be acutely altered, and will stabilize with thyroid replacement therapy."
a[152] = f + "(B) Incorrect. The parathormone may be decreased eventually, but measurement is of no value acutely."
a[153] = f + "(C) Incorrect. Changes in thyroxine levels do not explain these findings this acutely."
a[154] = f + "(D) CORRECT. The parathyroids can be inadvertently removed or traumatized with thyroid surgery, resulting in post-operative hypocalcemia. Post-surgical monitoring of calcium levels is routinely performed following thyroidectomy."
a[155] = f + "(E) Incorrect. Calcitonin is not involved in acute symptoms of decreased serum calcium. At physiologic levels, calcitonin doesn't do much in humans."
a[155.1] = f + "(F) Incorrect. Iodine deficiency is a rare cause for hypothyroidism which develops over a long period of time. Iodine levels are not often ordered."
a[156] = f + "(A) Incorrect. There may be transient hypo- or hyperthyroidism with this disease, but the gland shows granulomatous inflammation with destruction of follicles."
a[157] = f + "(B) Incorrect. The papillary infoldings of papillary carcinoma would be lined by neoplastic cells unlikely to be columnar, and the neoplasm would probably not be diffuse."
a[158] = f + "(C) Incorrect. This disease may lead to hyperthyroidism, but the gland is nodular. It is a less frequent cause for hyperthyroidism than Graves disease."
a[159] = f + "(D) Incorrect. Though the gland may be enlarged, there is extensive lymphoid infiltration, and though transient hyperthyroidism can occur, hypothyroidism occurs more often."
a[160] = f + "(E) CORRECT. Diffuse hyperplasia of the thyroid gland is typical for Graves disease. The TSH is low from negative feedback from the increased thyroid hormone production."
a[161] = f + "(A) Incorrect. Such alpha cell tumors are quite rare. They may be associated with a mild diabetes mellitus."
a[162] = f + "(B) Incorrect. Type I diabetes is typically complicated by ketoacidosis because of the severe insulin deficiency."
a[163] = f + "(C) Incorrect. Although there is impaired glucose tolerance with Cushing syndrome, the glucose is unlikely to reach this level."
a[164] = f + "(D) Incorrect. This would be highly unlikely from a physiologic standpoint."
a[165] = f + "(E) CORRECT. The complication of diabetes mellitus known as hyperosmolar coma is most typical for type II diabetes mellitus; most affected persons are overweight and have increased insulin resistance, not an absolute lack of insulin secretion. Thus, there is no ketoacidosis accompanying the hyperglycemia in hyperosmolar coma."
a[166] = f + "(A) CORRECT. Hepatic tumors are a long-term risk for anabolic steroid abuse. He may wish to look like a 'stud' but physiologically he is not, with hypogonadism as a consequence of the anabolic steroid abuse."
a[167] = f + "(B) Incorrect. Papillary carcinomas may arise in the setting of radiation exposure, not anabolic steroid abuse."
a[168] = f + "(C) Incorrect. Renal cell carcinomas may secrete androgens, but they are not induced by them."
a[169] = f + "(D) Incorrect. Though the muscle mass may increase, there is no cellular proliferation, so the risk for malignancy in muscle is not increased."
a[170] = f + "(E) Incorrect. Seminomas and other testicular carcinomas are not more frequent with anabolic steroid abuse."
a[171] = f + "(A) CORRECT. Forgotten about this obscure eponym? Extra-adrenal paraganglion tissue is found at a variety of sites, including at the bifurcation of the aorta near the origin of the median sacral artery, where the organ of Zuckerkandl is located. About 10% of pheochromocytomas are extra-adrenal."
a[172] = f + "(B) Incorrect. Paraganglion tissue is not found within the liver."
a[173] = f + "(C) Incorrect. Islet cell tumors can be located in the pancreas, and some of them may function to produce hormones such as insulin or gastrin, but not catecholamines."
a[174] = f + "(D) Incorrect. Paraganglion tissue is not likely to be found within the mediastinum."
a[175] = f + "(E) Incorrect. Paraganglion tissue is not likely to be found within the spleen or near the hilum."
a[176] = f + "(A) Incorrect. The findings point to hypothyroidism. An adenoma is unlikely to wipe out thyroid function, though secretion of thyroid hormone is possible."
a[177] = f + "(B) Incorrect. Hyperplasia is a finding of hyperthyroidism with Graves disease."
a[178] = f + "(C) Incorrect. Granulomatous thyroiditis may lead to transient hypothyroidism in adults, but usually not children. Hashimoto thyroiditis, however, may occur in children."
a[179] = f + "(D) Incorrect. Carcinomas are rare in children. The focal nature of metastases makes loss of thyroid function unlikely."
a[180] = f + "(E) CORRECT. The child is not living in a region of endemic goiter. His thyroid problem is probably a developmental failure of thyroid gland formation. Congenital hypothyroidism, though rare, is one of the diseases screened for at birth, because when recognized it can easily be treated with replacement thyroid hormone."
a[181] = f + "(A) Incorrect. This condition leads to extensive fibrosis. An autoimmune mechanism does not appear to be involved."
a[182] = f + "(B) Incorrect. Viral infections are thought to precede granulomatous thyroiditis. Autoantibodies are present in only a few of such patients."
a[183] = f + "(C) CORRECT. The most common condition in which thyroid autoantibodies are present is Hashimoto thyroiditis, but such antibodies may be present in other autoimmune conditions such as Graves disease. Microscopically, extensive lymphoid infiltrates also suggest autoimmunity as an etiology for thyroid disease. Early in the course of Hashimoto thyroiditis, the thyroid may be enlarged from this extensive inflammation."
a[184] = f + "(D) Incorrect. Thyroid autoantibodies may be found with Graves disease, particularly when it is associated with Hashimoto thyroiditis. Graves disease is associated with HLA DR3."
a[185] = f + "(E) Incorrect. Only a minority of patients with this condition have thyroid autoantibodies."
a[185.1] = f + "(F) Incorrect. Nodular goiter produces thyroid enlargement, but is not accompanied by thyroid autoantibodies."
a[186] = f + "(A) CORRECT. Meningococcemia is the usual cause for the Waterhouse-Friderichsen syndrome, with extensive adrenal hemorrhages and adrenal failure developing rapidly. Organisms other than <I>Neisseria meningitidis</I> are less commonly implicated."
a[187] = f + "(B) Incorrect. Lung cancers in particular like to metastasize to adrenal. Adrenal function may be wiped out, though this is not frequent, and the onset is not typically sudden."
a[188] = f + "(C) Incorrect. Tuberculosis was once the most common cause for Addison disease with a chronic course, but it is less frequent now that TB is being detected and treated more readily."
a[189] = f + "(D) Incorrect. The adrenal is one of the favorite places for amyloid deposition, but amyloidosis is not an acute process."
a[190] = f + "(E) Incorrect. The adrenals are in a protected location in the retroperitoneum, with plenty of surrounding fat, and they have three blood supplies, so traumatic loss of function is unlikely to occur."
a[191] = f + "(A) CORRECT. Multinodular goiter is the result of long-standing simple goiter. A toxic multinodular goiter (Plummer syndrome) occurs in less than half of patients with multinodular goiter. A hyperfunctioning nodule is the source for increased thyroid hormone."
a[192] = f + "(B) Incorrect. Her multinodular goiter is not a premalignant condition."
a[193] = f + "(C) Incorrect. Graves disease produces diffuse enlargement of the thyroid with increased thyroid hormone production from the onset."
a[194] = f + "(D) Incorrect. Viral infection is thought to precede subacute granulomatous thyroiditis, which may have transient hyperthyroidism, but not multinodular goiter. This disease runs a course of weeks, not years."
a[195] = f + "(E) Incorrect. This is more typical for Hashimoto thyroiditis, in which the thyroid may be initially enlarged, but then becomes atrophic over years' time."
a[196] = f + "(A) Incorrect. Gliomas are not associated with endocrine neoplasms."
a[197] = f + "(B) CORRECT. The findings of the thyroid neoplasm are consistent with a medullary carcinoma. The family history and the multifocality suggest a genetic basis, most likely a germline mutation in the RET proto-oncogene on chromosome 10, linked to cases of Sipple syndrome (MEN II). These patients may have parathyroid hyperplasia and pheochromocytomas. Overall, about 10% of medullary carcinomas have a familial genetic association, with autosomal dominant inheritance pattern."
a[198] = f + "(C) Incorrect. Angiosarcomas are sporadic and rare and not associated with endocrine neoplasms."
a[199] = f + "(D) Incorrect. Gastrinomas of the pancreas can be seen with multiple endocrine neoplasia (MEN) type I."
a[200] = f + "(E) Incorrect. Renal cell carcinomas may secrete a variety of substances with hormonal effect, but such cancers are not associated with endocrine neoplasms."
a[201] = f + "(A) CORRECT. Osteitis fibrosa cystica can be seen with secondary hyperparathyroidism as a consequence of chronic renal failure, though it is more often a complication of primary hyperparathyroidism."
a[202] = f + "(B) Incorrect. Fibrous dysplasia may be monostotic and sporadic, or it may be associated with McCune-Albright syndrome."
a[203] = f + "(C) Incorrect. Disorders of calcium metabolism are not a typical feature of osteosarcoma of bone."
a[204] = f + "(D) Incorrect. Benign bone tumors are generally not associated with disorders of calcium metabolism."
a[205] = f + "(E) Incorrect. Osteopetrosis is markedly dense bone and is not a feature of hyperparathyroidism, either primary or secondary."
a[206] = f + "(A) Incorrect. The underlying enzyme deficiency leads to adrenal enlargement, but not to ectopia."
a[207] = f + "(B) Incorrect. Such a carcinoma would be very rare at such an age, and a hernia sac is an unlikely spot for a metastasis."
a[208] = f + "(C) CORRECT. Small embryologic rests of adrenal cortex can be found in hernia sacs, testis, ovary, or kidney capsule. They may undergo the same changes as the adrenal glands proper. It is a human characteristic to misplace things, and this starts in embryologic life."
a[209] = f + "(C) Incorrect. Such ectopic adrenal has an insignificant amount of cortex and it will never be missed."
a[210] = f + "(E) Incorrect. Ectopic adrenal cortex is not part of MEN; it is a embryologic remnant from development of the adrenal."
a[211] = f + "(A) CORRECT. This vestigial midline remnant of thyroid development may become manifest at any age and is the most common clinically significant congenital thyroid anomaly. A thyroglossal duct (tract) cyst can be easily excised."
a[212] = f + "(B) Incorrect. Thyroid cancers are rare at this age (except with previous radiation exposure), and lymph node metastases are more common from papillary carcinomas."
a[213] = f + "(C) Incorrect. Adenomas are rare at this age. They would likely appear in right or left lobe and be palpable off the midline."
a[214] = f + "(D) Incorrect. Multinodular goiter produces diffuse, nodular thyroid enlargement, not a midline mass."
a[215] = f + "(E) Incorrect. Parathyroid cysts are an uncommon incidental finding at autopsy. They rarely exceed 1 cm."
a[216] = f + "(A) Incorrect. This is one cause for primary hyperparathyroidism. Such carcinomas are often associated with a very high calcium level."
a[217] = f + "(B) Incorrect. This is a cause for secondary hyperparathyroidism in which the serum calcium level may be normal to high, with a high serum phosphorus."
a[218] = f + "(C) Incorrect. This is a cause for secondary hyperparathyroidism in which the serum calcium level may be normal to high, with a high serum phosphorus."
a[219] = f + "(D) CORRECT. The deletion of chromosome 22q produces abnormalites in the 3rd and 4th pharyngeal pouches, which form thymus and parathyroids. The parathyroids may be absent in this condition, which can lead to hypoparathyroidism and hypocalcemia, as well as immunodeficiency from diminished cell mediated immunity. A partial DiGeorge syndrome is accompanied by less dramatic findings."
a[220] = f + "(E) Incorrect. This is a cause for primary hyperparathyroidism with hypercalcemia."
a[221] = f + "(A) CORRECT. The baby has congenital adrenal hyperplasia from lack of cortisol and salt-wasting, along with maculinization."
a[222] = f + "(B) Incorrect. Phenylketonuria not treated can lead to neurologic complications noted in childhood, but there are no electrolyte abnormalities."
a[223] = f + "(C) Incorrect. The baby does not have galactosemia, a condition that can be tested for at birth."
a[224] = f + "(D) Incorrect. The baby does not have vonGierke disease, which would produce hepatomegaly and hypoglycemia."
a[225] = f + "(E) Incorrect. There are rare inherited disorders of thyroid hormone metabolism which may result in cretinism."