ENDOCRINOLOGY

"ENDOCRINOLOGY"

MODULE: MODERN FOUNDATIONS OF DIAGNOSIS AND TREATMENT OF DISEASES OF THE HYPOTHALAMO-HYPOPHYSAL SYSTEM.

1. A 44-year-old man complains of a gradual increase in the size of the hands and feet, hardening of the facial features, increased sweating, headache, and joint pain; upon examination, BMI 30.4 kg/m2, BP 150/95 mm Hg, HR 82/min, prognatism, macroglossia, enlargement of the supraorbital arches and hands are noted; according to laboratory studies, the IFR-1 level is 682 ng/ml (Ref. 94-252 for age), basal STH 18.4 ng/ml (ref. <5), in oral glucose tolerance test with 75 g of glucose, STH suppression is not observed - 14.6 ng/ml (ref. <1), prolactin 520 mU/l (ref. 86-324), fasting glucose 7.2 mmol/l (ref. 3.9-5.5); contrast MRI of the pituitary gland revealed a 13×11 mm volumetric formation with suprasellar growth corresponding to macroadenoma.

Questions

1. What is the most likely clinical diagnosis?
2. What diseases should be considered in differential diagnosis?
3. What is the optimal patient management strategy according to modern clinical recommendations?

2. A 10-year-old boy  was referred for examination for pronounced growth retardation; according to parents, the child's height was significantly lower than his peers; upon examination, height was 120 cm (−3.1 SDS), body weight 24 kg, body proportions were preserved, BMI 16.7 kg/m2, secondary sexual characteristics were absent; according to laboratory studies, IFR-1 was 42 ng/ml (Ref. 95-350 for age), IFR-BP3 2.1 mg/l (ref. 3.4-6.0), basal STH 0.6 ng/ml (ref. <5), in the stimulation test with insulin hypoglycemia, the peak STH was 4.2 ng/ml (ref. >10), TSH 2.1 mIU/l (ref. 0.4-4.0), free T4 14.6 pmol/l (ref. 12-22); on MRI of the pituitary gland, adenohypophysis hypoplasia is observed without volumetric formations, and bone age according to hand radiography lags behind passport age by 3 years.

Questions

1. Which variant of short stature is most likely?
2. What additional reasons for growth retardation should be eliminated?
3. What is the optimal treatment and observation tactics for the child?

3. A 35-year-old woman  has been complaining of secondary amenorrhea for 10 months, galactorrhea, and decreased libido; upon examination, her BMI is 24.1 kg/m2, blood pressure is 115/75 mm Hg, and when the breasts are pressed, a colostrum-like secretion is released; according to laboratory studies, the level of prolactin is 2 480 mIU/l (Ref. 109-557), TSH 2.4 mU/l (ref. 0.4-4.0), free T4 15.2 pmol/l (ref. 12-22), FSH 4.2 IU/L (ref. 3.5-12.5), LH 3.8 IU/L (ref. 2.4-12.6), estradiol 96 pmol/l (ref. 110-730); MRI of the pituitary gland revealed a 7-mm volumetric formation corresponding to pituitary microadenoma.

Questions

1. What is the most likely diagnosis for this patient?
2. What causes of hyperprolactinemia should be considered during differential diagnosis?
3. What is the optimal treatment strategy according to modern recommendations?

4. A 50-year-old man  complains of pronounced general weakness, weight loss, decreased libido, absence of morning erections, and episodes of hypoglycemia; upon examination, BMI is 22.3 kg/m2, blood pressure is 95/60 mm Hg, heart rate is 88/min, skin is pale and dry, hair growth in the armpits and face is sharply reduced; according to laboratory studies, cortisol in the morning is 62 nmol/l (Ref. 140-690), ACTH 6.2 pg/ml (ref. 7-63), free T4 7.8 pmol/L (ref. 12-22), TSH 0.6 mU/l (ref. 0.4-4.0), total testosterone 4.1 nmol/l (ref. 12-33), LH 1.2 IU/L (ref. 1.7-8.6), FSH 1.6 IU/l (ref. 1.5-12.4), IFR-1 58 ng/ml (ref. 94-252); MRI of the sella turcica region reveals "empty sella turcica" syndrome with pronounced pituitary atrophy.

Questions

1. What syndrome is most likely in this patient?
2. Which hormonal axes are affected first?
3. What is the optimal sequence of hormone replacement therapy?

MODULE: TIREOIDOLOGY

5. The patient, 29 years old, has been complaining of a gradual increase in neck volume for about 3 years, a feeling of discomfort and a lump in the throat when swallowing, quick fatigue and chills; upon examination, her general condition is satisfactory, BMI 21.3 kg/m2, blood pressure 110/70 mm Hg, heart rate 68/min, the thyroid gland is diffusely enlarged, soft-elastic in consistency, painless, goiter of I-II degree according to the WHO classification, no clinical signs of thyrotoxicosis and hypothyroidism were detected; according to laboratory studies, the TSH level is 3.9 mIU/l (Ref. 0.4-4.0), free T4 - 13.1 pmol/l (ref. 12-22), free T3 - 4.2 pmol/l (ref. 3.1-6.8), antibodies to thyroid peroxidase - 18 IU/ml (ref. <35), antibodies to thyroglobulin - 42 IU/ml (ref. <115), thyroidoglobulin - 42 ng/ml (ref. <30), the median concentration of iodine in urine is 68 mcg/l (ref. ≥100), which indicates a chronic iodine deficiency; during ultrasound examination of the thyroid gland, the total volume is 23.6 ml (right lobe 12.4 ml, left lobe 11.2 ml), the echostructure is moderately heterogeneous, focal and nodular formations are not visualized, and intathyroid blood flow is not enhanced.

Questions

1. What is the most probable clinical diagnosis for this patient?
2. What nosological forms should be considered when conducting differential diagnosis in this case?
3. What is the optimal management and treatment tactics for the patient according to modern international clinical recommendations?

6. A 46-year-old patient  presented with complaints of pronounced fatigue, drowsiness, an increase in body weight by 8 kg over the past year with an unchanged diet, dry skin, chills, constipation, and decreased work capacity; upon examination, her condition was moderately severe, BMI 29.6 kg/m2, blood pressure 130/85 mm Hg, heart rate 56/min, dry and cold skin on palpation, face is pasty, moderate periorbital edema, tongue is enlarged with dental impressions, thyroid gland is not enlarged, firm consistency, painless; according to laboratory studies, the TSH level is 12.8 mIU/l (Ref. 0.4-4.0), free T4 - 8.6 pmol/l (ref. 12-22), free T3 - 3.0 pmol/l (ref. 3.1-6.8), antibodies to thyroid peroxidase - 680 IU/ml (ref. <35), antibodies to thyroidoglobulin - 420 IU/ml (ref. <115), total cholesterol - 7.2 mmol/l (ref. <5.0), LDL - 4.8 mmol/l (ref. <2.6), sodium - 134 mmol/l (ref. 135-145); during ultrasound examination of the thyroid gland, the total volume is 9.2 ml, the echostructure is diffusely hypoechoic and heterogeneous, the contours are uneven, no nodular formations are detected, and vascularization is reduced.

Questions

1. What is the most probable clinical diagnosis and its etiological form in this patient?
2. What conditions should be considered within the framework of differential diagnosis in this laboratory-instrumental picture?
3. What is the optimal tactics for managing and treating a patient in accordance with modern international clinical recommendations?

7. A 32-year-old patient  presented with complaints of rapid heartbeat, unmotivated weight loss of 6 kg over 3 months with preserved appetite, hand tremors, increased sweating, irritability, insomnia, and a feeling of "sandiness" in the eyes; upon examination, the condition was moderately severe, BMI 20.1 kg/m2, blood pressure 135/70 mm Hg, heart rate 112/min, the skin was warm and moist, small-span tremors of extended arms were noted, moderate exophthalmos with rare blinking, Grefe's sign was positive, the thyroid gland was diffusely enlarged to the II degree according to WHO, soft-elastic consistency, painless; according to laboratory studies, the TSH level was <0.01 mIU/l (ref. 0.4-4.0), free T4 42.8 pmol/l (ref. 12-22), free T3 12.6 pmol/l (ref. 3.1-6.8), antibodies to the TSH receptor 14.2 IU/L (ref. <1.75), antibodies to TPO 220 IU/ml (ref. <35), fasting plasma glucose 5.8 mmol/l (ref. 3.9-5.5); during ultrasound examination of the thyroid gland, the total volume is 28.4 ml, the echostructure is diffusely heterogeneous, with pronounced hypervascularization of the "thyroid inferno" type, and no nodular formations were detected.

Questions

1. What is the most probable clinical diagnosis for this patient?
2. What diseases and conditions should be considered when conducting differential diagnosis of thyrotoxicosis in this case?
3. What is the optimal tactics for managing and treating a patient in accordance with modern international clinical recommendations?

8. Patient  41 years old complains of general weakness, increased fatigue, decreased work capacity, periodic frostbite, and moderate increase in body weight by 4 kg over the past year; upon examination, condition is satisfactory, BMI 27.8 kg/m2, blood pressure 125/80 mm Hg, heart rate 64/min, skin is moderately dry, no periorbital edema, thyroid gland is slightly enlarged, dense in consistency, painless, diffusely heterogeneous on palpation; according to laboratory studies, TSH level is 6.2 mIU/l (Ref. 0.4-4.0), free T4 - 11.4 pmol/l (ref. 12-22), free T3 - 3.6 pmol/l (ref. 3.1-6.8), antibodies to thyroid peroxidase - 960 IU/ml (ref. <35), antibodies to thyroidoglobulin - 540 IU/ml (ref. <115), total cholesterol - 6.1 mmol/l (ref. <5.0); on ultrasound examination of the thyroid gland, the total volume is 14.8 ml, the echostructure is diffusely pronounced hypoechoic and heterogeneous, the contours are uneven, pseudo-nodular changes without true nodes are noted, intrathyroid blood flow is moderately reduced

Questions

1. What is the most probable clinical diagnosis and stage of the disease in this patient?
2. What diseases and conditions should be considered in the differential diagnosis, taking into account the clinical and laboratory picture?
3. What is the optimal tactics for managing the patient in accordance with modern international clinical recommendations?

9. The patient, 63 years old, complains of pain in the pelvic bones and spine, a decrease in height by 4 cm over the past 5 years, and frequent falls; upon examination, her condition is satisfactory, BMI 24.9 kg/m2, blood pressure 125/75 mm Hg, kyphotic deformity of the thoracic spine; according to laboratory studies, total calcium is 2.05 mmol/l (Ref. 2.15-2.55), ionized calcium 1.03 mmol/l (ref. 1.12-1.32), phosphorus 0.72 mmol/l (ref. 0.81-1.45), parathyroid hormone 128 pg/ml (ref. 15-65), 25 (OH) D 14 ng/ml (ref. 30-100), alkaline phosphatase 186 units/l (ref. 40-150); in DXA-densitometry, the T-score of the lumbar spine is −3.1, and in spinal X-rays, there are compression fractures of Th11-L1.

Questions

1. What calcium-phosphorus metabolism disorder is most likely in this case?
2. What additional studies are needed to clarify the pathogenesis of the identified changes?
3. What is the optimal tactics for managing the patient according to modern clinical recommendations?

METABOLIC SYNDROME

10. A 52-year-old man  complained of fatigue, shortness of breath with moderate exertion, and weight gain; upon examination, BMI was 34.8 kg/m2, waist circumference 118 cm, blood pressure 150/95 mm Hg, heart rate 78/min, acanthosis nigricans in the neck area; according to laboratory studies of glucose in the stomach 6.4 mmol/l (Ref. 3.9-5.5), HbA1c 6.1% (ref. <5.7), insulin on an empty stomach 32.4 mcE/ml (ref. 2.6-24.9), HOMA-IR 9.2 (ref. <2.5), triglycerides 2.9 mmol/l (ref. <1.7), HDL 0.86 mmol/l (ref. >1.0), LDL 4.3 mmol/l (ref. <2.6); on ultrasound of the abdominal organs - signs of fatty liver infiltration.

Questions

1. Does the clinical picture meet the criteria for metabolic syndrome?
2. What pathogenetic mechanisms underlie the identified disorders?
3. What is the optimal strategy for treating and preventing cardiovascular complications?

MODULE: DIABETOLOGY

11. A 19-year-old young man  was admitted with complaints of severe thirst, polyuria up to 6-7 l/day, weight loss of 9 kg over 2 months, and general weakness; upon examination, BMI was 18.7 kg/m2, blood pressure 105/65 mm Hg, heart rate 96/min, skin was dry; according to laboratory blood glucose tests, it was 18.6 mmol/l (Ref. 3.9-5.5), HbA1c 11.2% (ref. <5.7), C-peptide 0.18 ng/ml (ref. 0.9-7.1), insulin <1.0 μIU/ml (ref. 2.6-24.9), antibodies to GAD 128 IU/ml (ref. <5), ketones in urine +++; according to blood gas composition pH 7.31 (ref. 7.35-7.45).

Questions

1. What type of diabetes mellitus is most likely in this case?
2. What criteria confirm the autoimmune nature of the disease?
3. What is the tactics for urgent and subsequent patient management?

12. A 58-year-old man complains of thirst, frequent urination, and decreased vision; upon examination, BMI 32.1 kg/m2, waist circumference 114 cm, blood pressure 145/90 mm Hg; according to laboratory tests of glucose in the stomach 9.4 mmol/l (Ref. 3.9-5.5), HbA1c 8.6% (ref. <5.7), C-peptide 4.6 ng/ml (ref. 0.9-7.1), insulin 26.8 μIU/ml (ref. 2.6-24.9), HOMA-IR 11.2 (ref. <2.5); during ophthalmoscopy - initial manifestations of non-proliferative retinopathy.

Questions

1. What variant of diabetes mellitus is present in this case?
2. What factors determine the choice of initial sugar-lowering therapy?
3. What is the strategy for reducing the risk of microvascular complications?

13. The 60-year-old  patient with a 12-year history of type 2 DM has no complaints; upon examination, blood pressure is 155/95 mm Hg; according to laboratory tests, HbA1c is 8.1% (Ref. <7.0), creatinine 156 μmol/l (ref. 62-106), CKF (CKD-EPI) 46 ml/min/1.73 m2 (ref. >90), albuminuria 420 mg/day (ref. <30), potassium 4.8 mmol/l (ref. 3.5-5.1); on kidney ultrasound - moderate reduction of the cortical layer.

Questions

1. What stage of diabetic nephropathy is most likely?
2. What indicators are key for monitoring the progression of kidney damage?
3. What is the optimal tactics for nephro- and cardioprotection?

14. A 55-year-old  patient with type 2 diabetes mellitus has been complaining of burning, numbness, and pain in the feet for 10 years, which intensify at night; upon examination, there is a decrease in vibration and pain sensitivity according to the "sock" type, Achilles reflexes are reduced; according to laboratory studies, HbA1c 8.9% (Ref. <7.0), vitamin B12 310 pg/ml (ref. 200-900), TSH 2.1 mU/l (ref. 0.4-4.0); during electroneuromyography - a decrease in the speed of impulse transmission along the lesser and greater tibial nerves.

Questions

1. What diabetic complication is most likely in this case?
2. What conditions must be excluded during differential diagnosis?
3. What is the optimal treatment and control strategy for the symptoms?

15. A 47-year-old man  with a 15-year history of type 1 diabetes mellitus was brought by the ambulance team unconscious, according to relatives, 2 hours before hospitalization, pronounced sweating, tremor, a feeling of severe hunger, anxiety, and confusion of consciousness were noted after missing meals against the background of administering a normal dose of short-acting insulin; upon examination, the level of consciousness was I-degree coma, the skin was pale, sharply moist, BMI 24.6 kg/m2, blood pressure 140/85 mm Hg, heart rate 102/min, breathing was independent, there were no pathological respiratory types, and no focal neurological symptoms were detected; according to an express laboratory study, the level of glucose in capillary blood was 1.8 mmol/l (Ref. 3.9-5.5), venous plasma glucose 1.6 mmol/l (ref. 3.9-5.5), insulin 38.2 μIU/ml (ref. 2.6-24.9), C-peptide 0.12 ng/ml (ref. 0.9-7.1), ketone bodies in urine are negative, the pH of arterial blood is 7.39 (ref. 7.35-7.45), sodium 138 mmol/l (ref. 135-145), potassium 4.2 mmol/l (ref. 3.5-5.1); no focal or volumetric formations were detected on brain CT.

Questions

1. What type of coma is most likely in this patient, and what pathophysiological mechanisms underlie its development?
2. What conditions should be considered in the differential diagnosis of consciousness disorders in a patient with diabetes mellitus?
3. What is the optimal tactics for providing emergency care and subsequent patient management in accordance with modern clinical recommendations?

MODULE: PROBLEMS OF ADRENAL DISEASES.

16. A 38-year-old woman complains of progressive weight gain predominantly in the torso region, muscle weakness in the proximal parts of the extremities, arterial hypertension, menstrual cycle disorders, and the appearance of purple stripes on the skin; upon examination, her BMI is 31.8 kg/m2, blood pressure is 165/100 mm Hg, heart rate is 84/min, the face is moon-like, the skin is thinned, multiple purple stripes on the abdomen and hips, and proximal myopathy; according to laboratory studies, cortisol in the blood serum is 890 nmol/l in the morning (Ref. 140-690), cortisol at 23:00 - 610 nmol/l (ref. <120), daily excretion of free cortisol with urine is 420 mcg/day (ref. 20-90), ACTH 68 pg/ml (ref. 7-63), small dexamethasone test - no suppression of cortisol (cortisol 720 nmol/l), fasting glucose 6.9 mmol/l (ref. 3.9-5.5); on MRI of the pituitary gland, a 6 mm volumetric formation corresponding to microadenoma was detected.

Questions

1. Which variant of hypercorticism is most likely in this case?
2. What additional studies are needed to clarify the source of hypercorticism?
3. What is the optimal treatment strategy according to modern clinical recommendations?

17. A 46-year-old man complains of pronounced general weakness, weight loss by 7 kg over the past 6 months, dizziness when standing up, decreased appetite, and darkening of the skin; upon examination, BMI 20.2 kg/m2, BP 90/60 mm Hg, HR 92/min, pronounced hyperpigmentation of the skin folds, nipples, and oral mucosa; according to laboratory tests, cortisol is 78 nmol/l in the morning (Ref. 140-690), ACTH 186 pg/ml (ref. 7-63), sodium 128 mmol/l (ref. 135-145), potassium 5.9 mmol/l (ref. 3.5-5.1), fasting glucose 3.4 mmol/l (ref. 3.9-5.5), aldosterone 38 pg/ml (ref. 40-310); with CT of the adrenal glands, a decrease in their size without focal lesions is observed.

Questions

1. What form of adrenal insufficiency is most likely in this patient?
2. What additional tests are needed to confirm the diagnosis and clarify the etiology?
3. What is the optimal tactics for lifelong patient management according to modern recommendations?

18. A 7-year-old girl was referred for examination due to signs of premature adrenarche and accelerated growth; upon examination, her height exceeded the age norm by +2.1 SDS, with hirsutism, freckles, clitoregaly, and BP of 105/65 mm Hg; according to laboratory studies, 17-hydroxyprogesterone 48 nmol/l (ref. <6), cortisol in the morning 110 nmol/l (ref. 140-690), ACTH 142 pg/ml (ref. 7-63), testosterone 3.6 nmol/l (ref. <0.5 for age), DHEA-S 9.8 μmol/l (ref. 0.3-2.4), sodium 136 mmol/l (ref. 135-145), potassium 4.9 mmol/l (ref. 3.5-5.1); on hand radiography, the bone age is 3 years older than the passport age.

Questions

1. What form of BDN is most likely in this clinical case?
2. What additional tests are needed to confirm the diagnosis and molecular verification?
3. What is the optimal treatment and dynamic monitoring of the patient?

MODULE: URGENT ISSUES OF REPRODUCTIVE ENDOCRINOLOGY.

19. A 36-year-old man complains of decreased libido, erectile dysfunction, fatigue, and reduced muscle mass; upon examination, BMI is 26.2 kg/m2, blood pressure is 120/80 mm Hg, heart rate is 70/min, hair growth is weakened according to the male type, testicles are reduced to 12 ml according to the orchidometer; according to laboratory studies, total testosterone is 7.8 nmol/l (Ref. 12-33), free testosterone 165 pmol/l (ref. 220-750), LH 18.6 IU/L (ref. 1.7-8.6), FSH 22.4 IU/l (ref. 1.5-12.4), prolactin 210 mU/l (ref. 86-324), TSH 1.9 mIU/l (ref. 0.4-4.0); on ultrasound of the scrotum - decreased testicular volume, diffuse fibrous changes.

Questions

1. What type of male hypogonadism is most likely?
2. What reasons should be considered in differential diagnosis?
3. What is the optimal patient management tactics?

20. A 29-year-old man complains of absence of morning erections and decreased sexual desire; upon examination, BMI is 23.8 kg/m2, blood pressure is 115/75 mm Hg, heart rate is 66/min, testis volume is 18 ml; according to laboratory studies, total testosterone is 9.6 nmol/l (ref. 12-33), LH 3.2 IU/L (ref. 1.7-8.6), FSH 4.1 IU/L (ref. 1.5-12.4), prolactin 260 mU/l (ref. 86-324); when tested with human chorionic gonadotropin, testosterone levels rise to 19.8 nmol/l (Ref. >18), no pathological changes were detected on MRI of the pituitary gland.

Questions

1. How to interpret the results of the functional test?
2. What level of reproductive axis damage is most likely?
3. What further diagnostic steps are appropriate?

21. A 27-year-old woman  complains of primary amenorrhea; upon examination, BMI 19.4 kg/m2, secondary sexual characteristics are poorly developed; according to laboratory studies, estradiol is 62 pmol/l (Ref. 110-730), FSH 3.1 IU/L (ref. 3.5-12.5), LH 2.8 IU/L (ref. 2.4-12.6), prolactin 240 IU/L (ref. 109-557); during the gonadoliberin test, an adequate increase in FSH to 18.4 IU/L and LH to 22.6 IU/L is observed, while MRI of the pituitary gland shows no pathology.

Questions

1. What variant of hypogonadism is presumed based on the test results?
2. At what level is the regulation of reproductive function impaired?
3. What reasons should be excluded first?

22. A 34-year-old woman  has been complaining of secondary amenorrhea for 2 years, fever, and vaginal dryness; upon examination, her BMI was 22.6 kg/m2; according to laboratory tests, FSH was 46.8 IU/l (Ref. 3.5-12.5), LH 32.4 IU/L (ref. 2.4-12.6), estradiol 48 pmol/l (ref. 110-730), AMH 0.2 ng/ml (ref. 1.0-6.8), TSH 2.2 mU/l (ref. 0.4-4.0); on ultrasound of pelvic organs - decreased ovarian size, follicles are not visualized.

Questions

1. What diagnosis is most likely in this case?
2. What etiological factors must be considered?
3. What are the main directions of patient management?

23. A 52-year-old woman complains of absence of menstruation for 14 months, pronounced rashes, night sweats, and sleep disturbances; upon examination, BMI 28.4 kg/m2, blood pressure 135/85 mm Hg; according to laboratory studies, FSH 68.2 IU/l (Ref. 25-135 for postmenopause), LH 41.6 IU/l (ref. 14-52), estradiol 38 pmol/l (ref. <73), total cholesterol 6.7 mmol/l (ref. <5.0); in DXA densitometry, the T-score of the lumbar region is −1.9.

Questions

1. Does the clinical picture correspond to menopause?
2. What health risks are associated with this period?
3. What is the optimal management strategy for the patient?

24. A woman  of 25 years old complains of irregular menstrual cycle, excessive hair growth on her face and weight gain; upon examination, BMI 31.2 kg/m2, acanthosis nigricans in the armpit areas; according to laboratory studies, LG 14.8 IU/l (Ref. 2.4-12.6), FSH 4.6 IU/l (ref. 3.5-12.5), LH/FSH index 3.2, total testosterone 3.1 nmol/l (ref. 0.5-2.6), DHEA-S 8.6 μmol/l (ref. 1.7-7.7), insulin on an empty stomach 28.4 mcE/ml (ref. 2.6-24.9); on ultrasound of the ovaries - the volume of each greater than 12 ml, ≥20 follicles with a diameter of 2-9 mm along the periphery.

Questions

1. Does the clinical picture meet the diagnostic criteria for PCOS?
2. What endocrine and metabolic disorders underlie the disease?
3. What are the main directions of patient management?