First Aid Express 2018 workbook: ENDOCRINE page 1

Endocrine

Questions

EMBRYOLOGY
1. Which structure connects the thyroid gland with the tongue in early embryos? (p 320) __________

______________________________________________________________________________

2. How can you differentiate a thyroglossal duct cyst from a branchial cleft cyst? (p 320) __________

______________________________________________________________________________

ANATOMY
3. What are the three major zones of the adrenal cortex? Name the hormone secreted by each zone.
(p 320) ________________________________________________________________________

______________________________________________________________________________

4. What are the two divisions of the pituitary gland? List the hormones secreted by each division?

(p 321) ________________________________________________________________________

5. Where are the cell bodies that produce the hormones released by the posterior pituitary gland?

(p 321) _______________________________________________________________________

6. What are the three major cell types in the Islets of Langerhans? Name the hormone secreted by

each cell. (p 321) ________________________________________________________________

______________________________________________________________________________

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PHYSIOLOGY
7. Which two cell types have their glucose transport primarily controlled by insulin? By which specific

glucose transporter? (p 322) _______________________________________________________

8. What test will allow you to distinguish between high endogenous and high exogenous insulin?

(p 322) ________________________________________________________________________

9. Fill in the blanks and choose the correct answers to complete the mechanism by which β cells secrete
insulin. (p 322)

I. Glucose enters the cell via ___________transporter.

II. Glucose is catabolized, raising intracellular ATP.
III. ATP-dependent __________ channels ___________ (open/close), causing ___________
(depolarization/hyperpolarization) of the cell membrane.
IV. Voltage-gated ____________ channels ___________ (open/close).
V. ____________ enters the cell, disinhibiting the release of insulin-containing vesicles docked at
the cell membrane.
VI. Insulin is exocytosed into the bloodstream.

10. Which two molecules control the secretion of prolactin? Which hormone does prolactin control the
secretion of? (p 323) _____________________________________________________________

______________________________________________________________________________

11. What are the effects of antidiuretic hormone (vasopressin) on fluid volume and serum sodium con-

centration? Which of these is unique to ADH? (p 325) ___________________________________

______________________________________________________________________________

12. For each of the congenital bilateral adrenal hyperplasias in the chart, indicate whether blood
pressure and sex hormone levels are increased or decreased. (p 326)

Disease Blood Pressure Sex Hormones

11β-hydroxylase deficiency
17α-hydroxylase deficiency
21-hydroxylase deficiency

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 First Aid Express 2018 workbook: ENDOCRINE page 3

13. What enzyme catalyzes the conversion of testosterone to estradiol? What enzyme catalyzes the

conversion of testosterone to DHT? (p 326) ___________________________________________

14. Describe the regulation of cortisol secretion, including the relevant anatomic locations, cell types,

and trophic hormones? (p 327) ____________________________________________________

______________________________________________________________________________

15. Where does the inactive form of vitamin D come from? Where do the two hydroxylation steps

required to activate vitamin D occur? (p 328) __________________________________________

16. PTH _______________ (increases/decreases) serum calcium levels and _______________

(increases/decreases) serum phosphate levels. Vitamin D _______________ (increases/decreases)

serum calcium level and _______________ (increases/decreases) serum phosphate levels. (p 328)

17. How do T3 and T4 control the body’s metabolic rate? (p 329) ______________________________

______________________________________________________________________________

18. What is the difference between thyroid-binding globulin and thyroglobulin? (p 329) _____________

______________________________________________________________________________

19. Increased levels of sex hormone–binding globulins _______________ (increase/decrease) free

testosterone levels in men and _______________ (increase/decrease) free testosterone levels in
women. (p 329)

PATHOLOGY
20. What is the most common cause of Cushing syndrome? (p 331) __________________________

21. For a patient who is not taking steroids, what are other potential causes of Cushing syndrome?
(p 331) ________________________________________________________________________

______________________________________________________________________________

22. What are the common clinical manifestations of Cushing syndrome? (p 331) _________________

______________________________________________________________________________

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23. How is Cushing syndrome diagnosed? (p 331) _________________________________________

24. Is hyperkalemia seen in primary or secondary adrenal insufficiency? (p 332) __________________

25. What are the three common causes of Waterhouse-Friderichsen syndrome? (p 332) ___________

______________________________________________________________________________

26. What is the “rule of 10’s” for pheochromocytoma? What is the cell of origin for this tumor? (p 334)

______________________________________________________________________________

______________________________________________________________________________

27. What are the signs and symptoms of pheochromocytoma? (p 334) _________________________

______________________________________________________________________________

28. What is the primary symptom of the VIPoma neuroendocrine tumor, which secretes vasoactive

intestinal peptide? (p 334) __________________________________________________________

29. Compare and contrast the characteristics of hypothyroidism vs hyperthyroidism, using the chart.
(p 335)

Sign/Symptom Hypothyroidism Hyperthyroidism

Activity level
Bowel movements
Cardiovascular changes
Edema
Free T4
Hair texture
Reflexes
Skin changes
T3 uptake
Temperature
Total T4
TSH level
Weight

30. List five diseases characterized primarily by hypothyroidism. (p 336) _______________________

______________________________________________________________________________

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31. What is the difference between de Quervain thyroiditis and Riedel thyroiditis? (p 336) __________

______________________________________________________________________________

32. List two diseases characterized primarily by hyperthyroidism. (p 337) _______________________

______________________________________________________________________________

33. Name four types of thyroid cancer. Which is most common? (p 338) ________________________

______________________________________________________________________________

34. What is the Chvostek sign? (p 339) __________________________________________________

35. Primary hyperparathyroidism is characterized by _______________ (increased/decreased) calcium

levels and _______________ (increased/decreased) alkaline phosphatase, whereas secondary
hyperparathyroidism is characterized by _______________ (increase/decreased) calcium levels
and _______________ (increased/decreased) alkaline phosphatase. (p 340)

36. What does the mnemonic “stones, thrones, bones, groans, and psychiatric overtones” stand for?
(p 340) ________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

37. How is diabetes insipidus diagnosed? (p 342) _________________________________________

38. What are the causes of SIADH? (p 342) ______________________________________________

______________________________________________________________________________

39. What are the differences between DI and SIADH? (p 342) ________________________________

______________________________________________________________________________

40. What are the acute manifestations of diabetes mellitus type 1? (p 344) ______________________

______________________________________________________________________________

41. What are the chronic manifestations of poorly controlled diabetes? (p 344) ___________________

______________________________________________________________________________

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42. Compare and contrast the characteristics of type 1 vs type 2 diabetes, using the chart. (p 345)

Type 1 Type 2
Associated with obesity
Genetic predisposition
Glucose intolerance
Ketoacidosis
Need for insulin
Primary defect
Sensitivity to insulin
Typical age of onset

43. How can patients with diabetic ketoacidosis be recognized by their breath? (p 345) ____________

______________________________________________________________________________

44. What are the signs and symptoms of carcinoid syndrome? (p 346) _________________________

______________________________________________________________________________

45. In the chart, check which components are involved in the multiple endocrine neoplasias. (p 347)

MEN 1 MEN 2A MEN 2B

Pancreas
Parathyroid
Pituitary
Pheochromocytoma

PHARMACOLOGY
46. Name the three varieties of fast-acting insulin. What is the main use of fast-acting insulin compared
to long-acting insulin? (p 348) ______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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47. What is the most feared complication of metformin? Which patients have the highest risk? (p 348)

______________________________________________________________________________

48. Among insulin, metformin, sulfonylureas, and glitazones/thiazolidinediones, which can cause

hypoglycemia if taken in excess? (p 348) _____________________________________________

49. Which drugs are used to treat hyperthyroidism? (p 349) _________________________________

50. Which drugs are used to treat hypothyroidism? (p 349) __________________________________

51. Which drug is used to treat hyperphosphatemia? (p 350) _________________________________

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Answers

EMBRYOLOGY
1. Thyroglossal duct (a common site of ectopic thyroid tissue).

2. A thyroglossal duct cyst will move with swallowing whereas a branchial cleft cyst will not.

ANATOMY
3. Zona glomerulosa produces aldosterone, zona fasciculata produces cortisol, and zona reticularis
produces sex hormones.

4. Posterior pituitary: ADH (vasopressin), oxytocin. Anterior pituitary: FSH, LH, ACTH, TSH, prolactin,
GH, and β-endorphin. MSH is secreted from intermediate lobe of pituitary.

5. The hypothalamus.

6. β cells produce insulin. α cells produce glucagon, and δ cells produce somatostatin.

PHYSIOLOGY
7. Skeletal myocytes and adipocytes; by the GLUT4 transporter.

8. C-peptide is absent if the source of insulin is exogenous and present in high levels if the patient has
an insulinoma.

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 First Aid Express 2018 workbook: ENDOCRINE page 9

9.

I. Glucose enters the cell via GLUT-2 transporter.

II. Glucose is catabolized, raising intracellular ATP.

III. ATP dependent potassium channels close, causing depolarization of the cell membrane.

IV. Voltage-gated calcium channels open.

V. Calcium enters the cell, disinhibiting the release of insulin-containing vesicles docked at
the cell membrane.

VI. Insulin is exocytosed into the bloodstream.

10. Dopamine inhibits prolactin release; TRH stimulates. Prolactin inhibits GnRH, thus inhibiting the
hypothalamic-pituitary-gonadal axis.

11. ADH leads to increased fluid volume and decreased serum sodium concentration. Of the two,
decreased serum sodium concentration and osmolality is more unique to ADH (aldosterone also
increases fluid volume).

12.

Disease Blood Pressure Sex Hormones

11β-hydroxylase deficiency ↑ ↑
17α-hydroxylase deficiency ↑ ↓
21-hydroxylase deficiency ↓ ↑

13. Aromatase; 5α-reductase.

14. CRH stimulates release of ACTH in anterior pituitary, which prompts cortisol production in the zona
fasciculata of the adrenal cortex.

15. Inactive Vitamin D is absorbed from the diet or is synthesized in the skin when exposed to sunlight.
Activation of Vitamin D requires hydroxylation in the liver, then the kidney.

16. Increases; decreases; increases; increases.

17. By increasing Na+/K+-ATPase activity, which increases oxygen consumption, respiratory rate, and
body temperature.

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18. Thyroid-binding globulin is a transport protein that carries T4 and T3 through the bloodstream
(because they’re lipophilic). Thyroglobulin is a large precursor molecule synthesized by thyroid
follicles that is used to generate multiple T4 and T3 molecules.

19. Decrease; decrease.

PATHOLOGY
20. Exogenous corticosteroids.

21. Cushing disease (pituitary adenoma): 70%; ectopic ACTH (eg, small cell lung cancer): 15%;
adrenal tumor: 15%.

22. Weight gain (truncal obesity), moon facies, buffalo hump, skin thinning, striae, hypertension,
hyperglycemia, osteoporosis, amenorrhea, and immunosuppression.

23. Dexamethasone challenge.

24. Primary adrenal insufficiency.

25. Septicemia due to N meningitidis bacteremia, DIC, and endotoxic shock.

26. 10% are malignant, 10% are bilateral, 10% are extra-adrenal, 10% calcify, and 10% occur in kids.
Chromaffin cells are the cells of origin for pheochromocytoma.

27. Elevated blood Pressure, Pain (headache), Perspiration, Palpitations (tachycardia), and Pallor.
These “5 P’s” are episodic.

28. Secretory diarrhea.

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 First Aid Express 2018 workbook: ENDOCRINE page 11

29.

Sign/Symptom Hypothyroidism Hyperthyroidism

Activity level ↓ ↑
Bowel movements Constipation Diarrhea

Chest pain,
Bradycardia; dyspnea
Cardiovascular changes palpitations,
on exertion
arrhythmias

Edema Myxedema Pretibial myxedema

Free T4 ↓ ↑
Hair texture Coarse, brittle Fine
Reflexes ↓ ↑
Skin changes Dry, cool skin Warm, most skin

T3 uptake ↓ ↑

Temperature Cold intolerance Heat intolerance

Total T4 ↓ ↑
TSH level ↑ (if primary) ↓ (if primary)
Weight gain (low Weight loss (high
Weight
appetite) appetite)

30. Hashimoto thyroiditis, postpartum thyroiditis, cretinism, de Quervain thyroiditis, and Riedel
thyroiditis.

31. de Quervain (subacute) thyroiditis is a self-limited type of hypothyroidism that follows a flu-like
illness. Riedel thyroiditis involves fibrous replacement of the thyroid.

32. Graves disease, thyrotoxicosis, and toxic multinodular goiter.

33. Papillary thyroid carcinoma (most common), follicular, medullary, and anaplastic.

34. In hypoparathyroid patients, tapping of the facial nerve causes the facial muscles to contract.

35. Increased; increased; decreased; increased.

36. Renal calcium stones, polyuria (thrones), osteitis fibrosa cystica of bones, neuropsychiatric
disturbances (“psychiatric overtones”), and abdominal complaints (groans due to constipation).

37. Water deprivation test: urine osmolality doesn’t increase in response to water deprivation.
Response to desmopressin can distinguish between central and nephrogenic DI.

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38. Ectopic ADH (eg, small cell lung cancer), CNS disorder/head trauma, pulmonary disease, and
drugs such as cyclophosphamide.

39. DI denotes lack of ADH; SIADH denotes too much ADH. DI is characterized by intense thirst and
polyuria, with high serum osmolarity and low urine concentration. SIADH is characterized by
excessive water retention, with high urine osmolarity and low serum osmolarity.

40. Polydipsia, polyuria, polyphagia, weight loss, DKA (type 1), and hyperosmolar hyperglycemic state
(type 2).

41. Retinopathy, glaucoma, cataracts, nephropathy, atherosclerosis, CAD, peripheral vascular

occlusive disease, neuropathy, and gangrene.

42.

Type 1 Type 2
Associated with obesity No Yes
Genetic predisposition Weak Strong
Glucose intolerance Severe Mild to moderate
Ketoacidosis Common Uncommon
Need for insulin Always Sometimes
Primary defect Destruction of β cells Increased resistance to insulin
Sensitivity to insulin High Low
Typical age of onset <30 years >40 years

43. Increased ketogenesis results in accumulation of acetone and other ketones; when exhaled,
acetone gives breath a fruity odor.

44. Diarrhea, cutaneous flushing, asthmatic wheezing, and right-sided valvular disease.

45.

MEN 1 MEN 2A MEN 2B

Pancreas √
Parathyroid √ √
Pituitary √
Pheochromocytoma √ √

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 First Aid Express 2018 workbook: ENDOCRINE page 13

PHARMACOLOGY
46. Insulin aspart, lispro, and glulisine. Unlike long-acting insulin, which is used to maintain a normal
basal insulin level, fast-acting insulin is taken with meals to address abnormally elevated
postprandial glucose.

47. Lactic acidosis, especially in patients with renal insufficiency) or B12 deficiency.

48. Insulin and sulfonylureas can cause hypoglycemia if taken in excess

49. Propylthiouracil and methimazole.

50. Levothyroxine (T4) and liothyronine (T3).

51. Sevelamer.

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