A 33-year-old man presented with sudden onset of headache, chest pain and hypertension. Imaging revealed a right adrenal mass. He had regional hypokinesia on echocardiogram and elevated troponin, suggesting catecholamine-induced cardiomyopathy from a pheochromocytoma. The patient would be diagnosed with a right adrenal pheochromocytoma and treated with alpha-blockade to control blood pressure prior to tumor removal.

1. Topics covered on endocrinology
1)HHS
2)Hypothyroidism
3)Addisons
4) Pitutary apoplexy
5) Hypocalcemia
6)DI
7) Sick euthyroid
8) SIADH
9)Thyrotoxicosis
10)Pheochromocytoma
11) CSWS
12)Thyrotoxic periodic paralysis
13) Hypercalcemia

2. Que1
65 year male type II DM on metformin
Admitted in ER with lethargic state, hypotension
dehydrated
Sugars 550 mg/dl
Serum osmolality usually ≥350 mOsm/kg
Ketone absent
ABG: pH7.3, PCO2 34,PO2 77 HCO318.5 lactates
2
Na 150 meq/l , K 3.5 meq/l, Cl 108 meq/l
1. Clinical diagnosis?
2. What can be the precipitating event for this condition?

3. Ans1
1)HHS
2)Left psoas abscess

4. Que 2
A 39 year-old female presented with chest pain, dyspnea and lower limb edema for 1 day.
Bradycardia, muffled heart sounds and hypotension The further laboratory evaluation revealed a TSH
value of 69.3 miU/L and low T3 and free T4. Chest radiograph showed an enlarged cardiac silhouette.
1)What are the
echocardiogram
findings?
2)What is becks triad?

5. Ans 2
1)
Pericardial effusion
Diastolic RV compression
Abnormal ventricular septum motion
2)
Hypotension with a narrowed pulse pressure
Jugular venous distention (JVD)
Muffled heart sounds

6. Que 3
68 year female with h/o bullous pemphigoid and was on regular treatment since last 15 years .
Admitted for hip replacement surgery. Intra op uneventful
post op Hb was 10 gm/dl , wbc 15000
Post op day three fever and hypotension
Echo normal
Lung ultrasound A lines
Sr Na 110 meq/l , Sr k u5.9meq/l, Sr chl 87 meq/l
Glucose 54 mg/dl
1) Diagnosis
2)Treatment

7. Ans 3
1) Addison's crises
2)inj hydrocortisone 100 mg

8. Que 4
35 years female uneventful pregnancy . In postpartum sudden onset of severe headache, neck
stiffness, bilateral visual changes, ophthalmoplegia. Brought to ER in hypotension. BSL 56 mg/dl
MRI brain s/o sellar hemorrhage
1)Diagnosis
2)Management

9. Ans 4
1)Pituitary apoplexy (sheehans syndrome)
2)High dose glucocorticoids if no visual impairment. Urgent surgical decompression if progressive
visual loss and unconsciousness

10. Que 5
A 54-year-old woman undergoes thyroidectomy for follicular carcinoma of the thyroid. About 6 h after surgery,
the patient complains of tingling around her mouth. She subsequently develops a pins-and-needles sensation in
the fingers and toes. The nurse calls the physician to the bedside to evaluate the patient after she has severe
hand cramps when her blood pressure is taken. Upon evaluation, the patient is still complaining of intermittent
cramping of her hands. She has had no change in her vital signs and is afebrile and ECG was as below. What is
the next step in evaluation and treatment of this patient?
1)Diagnosis
2) How you will treat ?

11. Ans 5
1)QTc 510ms due to hypocalcaemia
Hypocalcaemia typically prolongs the ST segment, leaving the T wave unchanged
2) Administration of calcium gluconate, 2 g IV

12. Que 6
55 female case of pituitary adenoma underwent transphenoidal surgery. Duration of surgery
was approximate 8 hours. Postoperatively shifted to ICU Afebrile Pulse 80 /min, BP 135/ 86 mm
Hg (not on any inotropic agents) Adequately hydrated, urine output 1 ml/kg, Na 135 meq/l K 4.2
meq/l cl 99 meq/l On next day Urine output increased to 5ml/kg . Electrolyte panel showed Na
150 meq/l K 3 meq/l Cl 99 meq/l plasma osmolarity 350mosm/l , Urine osmolarity 210
mosmol/l
1)Diagnosis
2)Treatment

13. Ans 6
1)Primary diabetes insipidus
2) IV/ subcute/ nasal/oral DDAVP ( Synthetic analogue of AVP)

14. Que 7
A 44-year-old male is involved in a motor vehicle collision. He sustains multiple
long bone injuries. He is unresponsive in the field and is intubated for airway
protection. An IV line is placed. He is stabilized medically and on hospital day 2
undergoes successful open reduction and internal fixation of the right femur and
right humerus. Post op failed to wean. He was evaluated in detail and you
review his laboratory values.
TSH free 2.9 mIU/L (0.2–4.0 mIU/L )
Free T4 16 pmol/L (10–20 pmol/L )
Total T3 0.6 nmol/L (0.9–2.5 nmol/L)
1) Interpretation of thyroid profile
2)How will you treat this patient ?

15. Ans 7
1) Sick euthyroid
low total T3 level associated with normal T4 and thyroid-stimulating hormone
(TSH) levels. The absence of a high TSH level excludes primary hypothyroidism.
This pattern would fit a
2) No active management. Observation
Abnormalities in the levels of circulating TSH and thyroid hormone are thought
to result from the release of cytokines in response to severe stress

16. Que 8
44-year-old male, with no history of smoking, presented with complaining of
cough and dyspnea. Hemodynamically stable. No edema. Normal skin turgor. His
laboratory parameters were : Sr Na 110 meq/l , Sr k 4 meq/l, Sr chl 90 meq/l
Urine osmolality 310 plasma osmolality 262 mOsm/kg urinary Na+ > 34mmol/L
RFT normal. Computerized tomography scan is as follows:
1) What is your likely diagnosis
2) How you will treat ?

17. Ans 8
1) CT revealed abnormal hilar shadow in the left lung
2) Fluid restrict
Medications to decrease ADH secretion Demeclocycline, Tolvaptan
Conivaptan

18. Que 9
40-year-old woman posted for posterior spinal fusion. During the pre- anesthesia
evaluation she had tachycardia and hypertension which was optimised and posted for
surgery. Induction of anaesthesia was uneventful. Intr oprative she had rise in
temperature 100 °F, pulse 180 bpm with Atrial fibrillation and blood pressure 170/110
mmHg. ABG is pH 7.32 Paco2 55mmHg, Paco2 95 , Hco3 26. Na 138, K 4.2, Cl 102. Post op
recovery tachycardia was persistent with wide fluctuations in blood pressure. Thyroid
function test, sent as part of investigation profile showed:
Serum free thyroxine (FT4) level of 42.1pmol/L (reference range: 8.0-16.0pmol/L)
Serum thyroid stimulating hormone (TSH) at <0.01mIU/L (reference range: 0.45-
4.50mIU/L)
Thyroid-stimulating hormone receptor antibody >40IU/L (normal ≤2.0IU/L)
1)What is your likely diagnosis
2) How you will manage?

19. Ans 9
1) Graves’ disease
2)Nasogastric propylthiouracil, sodium iodide, IV hydrocortisone. Temperature
control with a cooling blanket. Judicious low dose esmolol infusion to manage
the tachycardia.

20. Que 10 A 33-year-old man, without known co-morbidities, was brought into the emergency
department with sudden onset of headache and severe central chest pain, radiating to the back. Heart
rate 105 beats per minute, blood pressure was 180/125 mmHg, temperature 36.1°C, oxygen-
saturation 98% and the respiratory-rate was 28 per minute. An arterial blood gas (ABG) revealed
significant lactate acidosis with pH 7.14, pO2 of 15.4 kPa, pCO2 of 4.5 kPa, bicarbonate of 12 mEq/L,
base excess of −16 mmol/L and lactate value of 12 mmol/L.
Bedside echocardiography revealed regional
hypokinesia in the lateral area of the left
ventricle, and an estimated left ventricular
ejection fraction (LVEF) of 20–30%. The
patients’ blood samples demonstrated
abnormal with a troponin T of 300 ng/L,
white blood cell count of 39 × 109/L and
normal c-reactive protein. Non enhanced CT
is as shown.
1)What is your diagnosis
2) What is the likely cause of poor cardiac
dysfunction?

21. Ans 10
1) Right adrenal pheochromocytoma
2) Catecholamine-induced or takotsubo-like cardiomyopathy

22. Que 11 CSWS
56 year female presented with excruciating headache altered level of
consciousness diagnosed to have subarachnoid haemorrhage due to aneurysmal
bleed. She was operated for the same uneventful, conscious oriented. 4 days
later found to be drowsy. Only abnormality was raised haematocrit and
abnormal electrolytes panel: Sr Na 120 meq/l , Sr k u 4.1meq/l, Sr chl 90 meq/l.
Urine sodium was 49 meq/L. Urine osmolality was 145 mosmol/kg
1) Diagnosis
2) How you will manage ?

23. Ans 11
1) Cerebral salt wasting syndrome
2) Mild to moderate hyponatremia : isotonic saline . isotonic fluid provides the
fluid for the hypovolemic patient as well as helps to restore the body's sodium
stores.
Moderate to severe hyponatremia: more aggressive sodium replenishment may
be required with either hypertonic saline 3% hypertonic saline and/or salt tabs
(1 to 2 grams up to three times daily) and fludrocortisone

24. Que12
30 year ypung male presented in ER with severe flaccid weaknes. He was on carbimazole for his
hyperthyroid status which was ceased since few months. His routine check up has shown
following ECG findings.
1)What is your likely diagnosis ? 2) what is the abnormality in ECG?

25. Ans 12
1)Thyrotoxic periodic paralysis
2) ECG shows QT prolongation, T-wave flattening and prominent U-wave.

26. Que 13
61 years old female presented to ER with confusion and debility. She appeared
grossly dehydrated. Since one month she had history of progressive back pain and
was immobilized. You are asked to review the laboratory reports.
1) What is the
abnormality?
2) Most common
cause ?

27. Ans 13
1) Hypercalcemia
2)Malignancy ( metastasis, primary bone disease),hyperparathyroidism , granulomatous disease