Endocrine Disorders, Free CME Quiz, Earn Free CME Credit
A free Endocrine Disorders question included below. The full Endocrine Disorders CME quiz is free online for a limited time. You can earn AMA CME credit - and now you can earn ANCC contact hours as well! Play now.
Here's this week's sample CME board review question on Endocrine Disorders:
A 35-year-old man presents with fatigue, loss of libido, and lethargy for the last 3 years. He has no medical history. He takes a multivitamin but no other medications. He smokes 1 pack of cigarettes every week and drinks 1 glass of wine each night. He does not use drugs. He is the manager at a retail clothing store.
His review of symptoms is notable for a 15-pound weight loss since his last visit 3 years ago. Vitals are: temperature 37.4 °C, heart rate 95 beats/minute, blood pressure 110/65 mm Hg, respiratory rate 14 breaths/minute, and oxygen saturation 99% on room air. Findings on his head, ears, eyes, nose, and throat examination as well as examinations of his neck, heart, lung, abdomen, and neurologic status are all normal. His skin appears tanned, even under his clothes.
You order laboratory studies that show a normal complete blood count, sodium level of 130, potassium level of 5.1, chloride level of 110, bicarbonate level of 25, blood urea nitrogen level of 13, creatinine level of 0.8, and glucose level of 90. The early morning serum cortisol level is 2.5 µg/dL. You suspect primary adrenal insufficiency.
What is the next test to confirm this suspected diagnosis?
The correct answer is:
standard high-dose short adrenocorticotropic hormone (ACTH) stimulation test
Discuss the sequence of recommended tests for differentiating primary versus secondary adrenal insufficiency.
Once the diagnosis of adrenal insufficiency is suspected, an ACTH level should be drawn to localize the defect to the adrenal gland or the hypothalamic-pituitary axis.
This patient shows the classical hyperpigmentation associated with primary adrenal deficiency and hence this is the most likely diagnosis. However, this impression should be confirmed with an ACTH stimulation test.
The low- and high-dose ACTH stimulation tests have similar rates of sensitivity and specificity. The current Endocrine Society guidelines recommend the use of the standard high-dose test after confirmation of a low serum or urine morning cortisol level. A morning cortisol level below 3 µg/dL is specific for adrenal insufficiency, and a morning cortisol level of >20 µg/dL following ACTH stimulation excludes adrenal insufficiency.
Bope ET, Kellerman RD. Endocrine and Metabolic Disorders. Book Chapter in Conn's Current Therapy 2017, 5, 243-345.
Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
Bleicken B, Hahner S, Ventz M, Quinkler M. Delayed diagnosis of adrenal insufficiency is common: a cross-sectional study in 216 patients. Am J Med Sci. 2010;339(6):525-531.
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