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USMLE® Step 1 style questions USMLE

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A 41-year-old woman comes to her outpatient provider because of skin changes that began three-months ago. She has noticed increased bruising and the development of purple-red stretch marks on the abdomen. Past medical history is notable for asthma, for which she intermittently uses a budesonide inhaler. She smokes half-a-pack of cigarettes per day. In the office, her temperature is 37.7°C (99.9°F), pulse is 71/min, respirations are 19/min, and blood pressure is 142/85 mmHg. Physical exam confirms the presence of ecchymoses and abdominal striae. Laboratory testing reveals the following findings:

 Laboratory value  Result 
 Sodium  146 mmol/L 
 Potassium  3.9 mmol/L 
 Bicarbonate  26 mmol/L 
 Fasting glucose  137 mg/dL 
 24-hour urine cortisol 72 µg/day 
 Serum ACTH**  35 pg/mL 

*Normal range: 4-40 µg/day
**Normal range: 5-20 pg/mL

The serum cortisol levels are significantly reduced in response to a high-dose of dexamethasone. Which of the following is the most likely underlying pathophysiology for this patient’s condition?

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Hyperpituitarism refers to a condition in which the pituitary gland secretes abnormally high levels of pituitary hormones. Hyperpituitarism typically results from a pituitary adenoma, which overproduces one or more of the pituitary hormones.

The symptoms depend on the type and size of the adenoma and the hormones it produces. However, hyperpituitarism associated with large adenomas may cause mass effect, which is characterized by headache and possibly bitemporal hemianopsia due to compression of the optic chiasma. Other common hormone-related symptoms may include: Abnormal growth or enlargement of the head, hands, and feet Developmental delays in children Diabetes mellitus Reproductive problems in men and women Enlarged thyroid gland (goiter) Increased blood pressure


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