Pathology - endocrine system

A 28-year-old man has been using insulin injections to control his diabetes mellitus for the past 10 years. One morning, his roommate is unable to awaken him. The man is unconscious when he arrives at the emergency department. On physical examination, his temperature is 37°C, pulse is 91/min, respirations are 30/min and forceful, and blood pressure ism90/65 mm Hg. Laboratory findings include a high plasma level of insulin and a lack of detectable C peptide. Urinalysis
shows no blood, protein, or glucose, but 4+ ketonuria. Which of the following conditions is most likely to be present?
□ (A) Acute myocardial infarction
□ (B) Bacteremia
□ (C) Hepatic failure
□ (D) Hyperosmolar coma
□ (E) Hypoglycemic coma
□ (F) Ketoacidosis
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A 28-year-old man has been using insulin injections to control his diabetes mellitus for the past 10 years. One morning, his roommate is unable to awaken him. The man is unconscious when he arrives at the emergency department. On physical examination, his temperature is 37°C, pulse is 91/min, respirations are 30/min and forceful, and blood pressure ism90/65 mm Hg. Laboratory findings include a high plasma level of insulin and a lack of detectable C peptide. Urinalysis
shows no blood, protein, or glucose, but 4+ ketonuria. Which of the following conditions is most likely to be present?
□ (A) Acute myocardial infarction
□ (B) Bacteremia
□ (C) Hepatic failure
□ (D) Hyperosmolar coma
□ (E) Hypoglycemic coma
□ (F) Ketoacidosis
E
A 28-year-old, otherwise healthy man sees his physician because he has had headaches for the past 2 weeks. Physical examination yields no remarkable findings except for a blood pressure of 170/110 mm Hg. An abdominal CT scan shows an enlarged right adrenal gland. A right adrenalectomy is done; the figure shows the gross appearance of the specimen. Which of the following laboratory findings was most likely reported in this patient?
□ (A) Hyponatremia
□ (B) Hyperglycemia
□ (C) Low serum renin level
□ (D) Hyperkalemia
□ (E) Low serum corticotropin level
C
A 60-year-old woman has felt a "lump" on the right side of her neck for several months. On physical examination, she
has a firm 3-cm mass in the right lobe of the thyroid gland. There is no palpable lymphadenopathy. Laboratory studies show a serum TSH level of 3 mU/L and a T4 level of 8.8 µg/dL. A fine-needle aspiration biopsy is done, and she undergoes a thyroidectomy. A 3-cm solid mass is present within the right thyroid lobe. Six months later, she visits her
physician again because of pain in the right thigh. A radiograph shows a fracture of the right femur in an area of lytic bone destruction. A radioiodine scan shows uptake localized to the region of the fracture. Which of the following was most likely to have been present in the patient's thyroid gland?
□ (A) Anaplastic carcinoma
□ (B) Follicular carcinoma
□ (C) Granulomatous thyroiditis
□ (D) Hashimoto thyroiditis
□ (E) Medullary carcinoma
□ (F) Non-Hodgkin lymphoma
B
A 40-year-old man sees his physician because of weight loss, increased appetite, and double vision. On physical examination, his temperature is 37.7°C, pulse is 106/min, respirations are 15/min, and blood pressure is 140/80 mm Hg. A fine tremor is observed in his outstretched hands. He has bilateral proptosis and corneal ulceration. Laboratory findings include a serum TSH level of 0.1 µU/mL. A radioiodine scan indicates increased diffuse uptake throughout the thyroid. He receives propylthiouracil therapy, and his condition improves. Which of the following best describes the microscopic
appearance of the patient's thyroid gland?
□ (A) Destruction of follicles, lymphoid aggregates, and Hürthle cell metaplasia
□ (B) Papillary projections in thyroid follicles and lymphoid aggregates in the stroma
□ (C) Follicular destruction with inflammatory infiltrates containing giant cells
□ (D) Nodules with nests of cells separated by hyaline stroma that stains with Congo red
□ (E) Enlarged thyroid follicles lined by flattened epithelial cells
A
Blood relatives of individuals diagnosed with type 1 or type 2 diabetes mellitus are studied for 10 years. Laboratory testing for glucose and insulin levels and autoantibody formation is performed on a periodic basis. The HLA types of the subjects are determined. A subset of the subjects 8 to 22 years old has no overt clinical illnesses and no hyperglycemia; however, autoantibodies to glutamic acid decarboxylase are present. Many subjects in this subset have the HLA-DR3 and HLA-DR4 alleles. Which of the following pancreatic abnormalities is most likely to be found in this subset of study
subjects?
□ (A) Acinar acute inflammation and necrosis
□ (B) Acinar fibrosis and fatty replacement
□ (C) Islet amyloid deposition
□ (D) Islet hyperplasia
□ (E) Insulitis
E
A 22-year-old woman has experienced increasing fatigue and a 7-kg weight loss without dieting over the past 4 months. She also has experienced increasing anxiety and nervousness with no apparent changes in her job or home life. She now has diarrhea. Physical examination shows a diffusely enlarged thyroid gland. Her temperature is 37.6°C, pulse is 103/min, respirations are 17/min, and blood pressure is 135/75 mm Hg. A radionuclide scan of the thyroid shows a diffuse increase in uptake. The figure shows the representative microscopic appearance of the thyroid gland at high power. What is most likely to produce these findings?
□ (A) Antibodies against TSH receptor
□ (B) Dietary deficiency of iodine
□ (C) Mutation in the RET proto-oncogene
□ (D) Maternal deficiency in T
4
□ (E) Irradiation of the neck
A
A 43-year-old man felt a small "bump" on the right side of his neck 1 month ago, and it has not changed since then.
Physical examination shows a 1-cm nodule palpable in the right lower pole of the thyroid gland. There is no lymphadenopathy. A fine-needle aspiration biopsy of the nodule is done, and the nodule has the cytologic features of a follicular neoplasm. Radionucleotide scanning shows that the nodule does not absorb radioactive iodine, and no other nodules are present. Based on these findings, which of the following is most likely to be present in this patient?
□ (A) Anti-TSH receptor immunoglobulins
□ (B) High free T4 and low TSH
□ (C) Normal free T4and TSH
□ (D) Low free T4 and elevated TSH
□ (E) Antimicrosomal (thyroid peroxidase) antibody
C
A 50-year-old man has a 35-year history of diabetes mellitus. During this time, he has had hemoglobin A
1c values between 7% and 10%. He now has problems with sexual function, including difficulty attaining an erection. He also is plagued by mild but recurrent low-volume diarrhea and difficulty with urination. These problems are most likely to originate from which of the following mechanisms of cellular injury?
□ (A) Apoptosis
□ (B) Coagulative necrosis
□ (C) Hyaline deposition
□ (D) Leukocytic infiltration
□ (E) Nonenzymatic glycosylation
□ (F) Sorbitol accumulation
F
!A 55-year-old man has experienced increasing lethargy for the past 7 months. Physical examination shows
hyperpigmentation of the skin. Vital signs include temperature of 36.9°C, pulse of 70/min, respirations of 14/min, and blood pressure of 95/65 mm Hg. Laboratory studies include a serum cortisol level of 3 µg/mL at 8:00 am with a serum corticotropin level of 65 pg/mL. Which of the following diseases is most likely to accompany this disorder?
□ (A) Systemic lupus erythematosus
□ (B) Hashimoto thyroiditis
□ (C) Diabetes mellitus type 2
□ (D) Ulcerative colitis
□ (E) Polyarteritis nodosa
B
!A 40-year-old woman has experienced lethargy, weakness, and constipation for the past 6 months. On physical examination, she is afebrile and normotensive, and her heart rate is slightly irregular. There is pain on palpation of the left third proximal finger. An ECG shows a prolonged QT (corrected) interval. Laboratory studies show Na +, 142 mmol/L; K+,4 mmol/L; Cl−, 95 mmol/L; CO2, 24 mmol/L; glucose, 73 mg/dL; creatinine, 1.2 mg/dL; calcium, 11.6 mg/dL; phosphorus, 2.8 mg/dL; total protein, 7.1 g/dL; albumin, 5.3 g/dL; alkaline phosphatase, 202 U/L; and total bilirubin, 0.9 mg/dL. A
radiograph of the left hand shows focal expansion by a cystic lesion of the third proximal phalanx. A radionuclide scan shows a 1-cm area of increased uptake in the right lateral neck. Which of the following mutations is most likely to precede the development of these findings?
□ (A) GNAS1
□ (B) MEN1
□ (C) NF1
□ (D) RET
□ (E) RB1
□ (F) p53
□ (G) VHL
B
A 45-year-old, otherwise healthy man feels a small lump on the left side of his neck. His physician palpates a firm, painless, 1.5-cm cervical lymph node. The thyroid gland is not enlarged. A chest radiograph is unremarkable. Laboratory findings include serum glucose, 83 mg/dL; creatinine, 1.2 mg/dL; calcium, 9.1 mg/dL; phosphorus, 3.3 mg/dL; thyroxine, 8.7 µg/dL; and TSH, 2.3 mU/L. The hemoglobin is 14 g/dL, platelet count is 240,400/mm3, and WBC count is 5830/mm3. A fine-needle aspiration biopsy of the thyroid gland is done, and the cells are examined microscopically. What is the most likely diagnosis? □ (A) Papillary carcinoma □ (B) Parathyroid carcinoma □ (C) Medullary carcinoma □ (D) Follicular carcinoma □ (E) Anaplastic carcinoma □ (F) Small lymphocytic lymphomaA!A 23-year-old man has experienced headaches, polyuria, and visual problems for the past 3 months. On physical examination, he has bilateral temporal visual field defects. CT scan of the head shows a large, partially calcified, cystic mass in the sellar and suprasellar areas. Laboratory findings show a serum prolactin concentration of 60 ng/mL and serum sodium level of 152 mEq/L. Serum calcium, phosphate, and glucose levels are normal. The mass is excised, and histologic examination shows a mixture of squamous epithelial elements and lipid-rich debris containing cholesterol crystals. Which of the following lesions is most consistent with the clinical laboratory findings in this patient? □ (A) Craniopharyngioma that has destroyed the posterior pituitary □ (B) Prolactin-secreting adenohypophyseal macroadenoma □ (C) Multiple endocrine neoplasia type I □ (D) Metastases from a lung neoplasm in the sella and brain □ (E) Multiple endocrine neoplasia type IIA!A 25-year-old woman has noted breast secretions for the past month. She is not breastfeeding and has never been pregnant. She has not menstruated for the past 5 months. Physical examination yields no abnormal findings. MRI of the brain shows a 0.7-cm mass in the adenohypophysis. Which of the following additional complications is most likely to be present in this patient? □ (A) Acromegaly □ (B) Cushing disease □ (C) Hyperthyroidism □ (D) Infertility □ (E) Syndrome of inappropriate antidiuretic hormoneDA 33-year-old woman has had several "fainting spells" over the past 6 months. Each time, she has a prodrome of lightheadedness followed by a brief loss of consciousness. After each episode, she awakens and on examination has no loss of motor or sensory function. Physical examination after the current episode shows that she is afebrile, with a pulse of 72/min, respirations of 14/min, and blood pressure of 120/80 mm Hg. On the basis of the microscopic finding shown in the figure, which of the following disorders is most likely to be present in this patient? □ (A) Adenocarcinoma □ (B) Acute pancreatitis □ (C) Islet cell adenoma □ (D) Pseudocyst □ (E) Fatty replacementCA 45-year-old woman had frequent headaches for about 1 month. She suddenly experienced a generalized seizure and became obtunded. She is taken to the emergency department, where a physical examination indicates no abnormalities. Laboratory findings include serum calcium of 15.4 mg/dL, serum phosphorus of 1.9 mg/dL, and albumin of 4.2 g/dL. A chest radiograph shows multiple lung masses, and there are lytic lesions of the vertebral column. Which of the following conditions best accounts for these findings? □ (A) Parathyroid carcinoma □ (B) Renal failure □ (C) Metastatic breast cancer □ (D) Vitamin D toxicity □ (E) TuberculosisCAn infant is born at term to a 25-year-old woman. On newborn physical examination, the infant is found to have an enlarged abdomen, but there are no other abnormal findings except for slightly elevated blood pressure. An abdominal ultrasound scan shows a right retroperitoneal mass in the adrenal gland. Which of the following laboratory findings is most likely to be reported in this neonate? □ (A) Increased urinary homovanillic acid (HVA) level □ (B) Decreased serum calcium level □ (C) Increased urinary free catecholamine level □ (D) Increased serum corticotropin level □ (E) Increased serum growth hormone level □ (F) Increased serum prolactin level □ (G) Increased serum cortisol levelA!A clinical study is conducted in patients diagnosed with either type 1 or type 2 diabetes mellitus. The family histories and past medical histories of the patients are analyzed. Laboratory testing determines their HLA types. Their levels of plasma insulin, glucagon, C peptide, hemoglobin A 1c, and autoantibodies to islet cells and insulin are measured. Which of the following features common to patients with either type 1 or type 2 diabetes mellitus is most likely to be found by this study? □ (A) Association with certain MHC class II alleles □ (B) Concordance rate of more than 90% in monozygotic twins □ (C) Marked resistance to the action of insulin □ (D) Nonenzymatic glycosylation of proteins □ (E) Presence of islet cell antibodiesEA 40-year-old woman notices that her gloves from the previous winter no longer fit her hands. Her friends remark that her facial features have changed in the past year, and that her voice seems deeper. On physical examination, she is afebrile. Her blood pressure is 140/90 mm Hg. She has coarse facial features. There is decreased sensation to pinprick over the palms in the distribution of her thumb and first two fingers. A radiograph of the foot shows an increased amount of soft tissue beneath the calcaneus. A chest radiograph shows cardiomegaly. Laboratory studies indicate a fasting serum glucose level of 138 mg/dL and hemoglobin A 1c level of 8.6%. Which of the following additional test results is most likely to indicate the cause of these physical and laboratory findings? □ (A) Elevated serum prolactin level □ (B) Failure of growth hormone suppression □ (C) Increased serum cortisol level □ (D) Abnormal glucose tolerance test result □ (E) Increased serum TSH levelBFor the past 7 months, a 44-year-old woman has become increasingly listless and weak and has had chronic diarrhea and a 5-kg weight loss. She also notices that her skin seems darker, although she rarely goes outside because she is too tired to participate in her usual outdoor activities. On physical examination, she is afebrile, and her blood pressure is 85/50 mm Hg. A chest radiograph shows no abnormal findings. Laboratory findings include serum Na+, 120 mmol/L; K+5.1 mmol/L; glucose, 58 mg/dL; urea nitrogen, 18 mg/dL; and creatinine, 0.8 mg/dL. The serum corticotropin level is 82 pg/mL. What is most likely to account for these findings? □ (A) Adenohypophyseal adenoma □ (B) Autoimmune destruction □ (C) Islet cell adenoma □ (D) Metastatic carcinoma □ (E) Neisseria meningitidis infection □ (F) SarcoidosisB!A 23-year-old woman has a routine health status examination. Her body mass index is 22. Laboratory studies show fasting plasma glucose is 120 mg/dL. Urinalysis shows mild glucosuria, but no ketonuria or proteinuria. She has no detectable insulin autoantibodies. Her father was similarly affected at age 20. She is most likely to have a mutation in a gene encoding for which of the following? □ (A) Glucagon □ (B) Glucokinase □ (C) GLUT4 □ (D) Insulin □ (E) MHC DRB!A 67-year-old woman has experienced malaise and a 10-kg weight loss over the past 4 months. She also has developed a chronic cough during this time. Physical examination shows muscle wasting and 4/5 motor strength in all extremities. Abdominal CT scan shows bilaterally enlarged adrenal glands. A chest radiograph shows a 6-cm perihilar mass on the right and prominent hilar lymphadenopathy. Laboratory studies show Na+, 118 mmol/L; K+, 6 mmol/L; Cl−,95 mmol/L; CO2, 21 mmol/L; and glucose, 49 mg/dL. Her 8:00 am serum cortisol level is 9 ng/mL. What is the most likely diagnosis? □ (A) Meningococcemia □ (B) Pituitary adenoma □ (C) Amyloidosis □ (D) Metastatic carcinoma □ (E) Ectopic corticotropin syndromeD