Add: new questions on subclinical hyperthyroidism, primary hyperparat…

…hyroidism, diabetic foot infections, Cushing's syndrome diagnosis, and complex DKA management

questions/endocrinology/adrenal/cushings.md

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+---
+id: ENDO006
+specialty: endocrinology
+topic: adrenal
+difficulty: hard
+tags: [endocrine, diagnosis, treatment, imaging, copilot, claude35Sonnet]
+created: 2025-01-06
+lastUpdated: 2025-01-06
+---
+
+# Cushing's Syndrome Diagnosis
+
+## Question
+A 35-year-old woman presents with:
+- 18-month history of weight gain
+- Easy bruising
+- Proximal muscle weakness
+- Depression
+- New-onset hypertension
+- Irregular menses
+
+Physical exam:
+- Central obesity
+- Moon facies
+- Purple striae
+- Buffalo hump
+- BP: 158/92 mmHg
+
+Initial testing:
+- 24h UFC: 280 µg/24h (normal <50)
+- 1mg overnight DST cortisol: 12 µg/dL (331 nmol/L)
+- ACTH: 85 pg/mL (18.7 pmol/L)
+- 8am cortisol: 28 µg/dL (772 nmol/L)
+- Midnight salivary cortisol: 0.35 µg/dL (9.7 nmol/L)
+
+Which next diagnostic step is most appropriate?
+
+## Options
+| Option | Description |
+|--------|-------------|
+| A)     | Pituitary MRI with contrast |
+| B)     | High-dose dexamethasone suppression test |
+| C)     | CRH stimulation test |
+| D)     | Bilateral inferior petrosal sinus sampling |
+| E)     | CT chest/abdomen/pelvis |
+
+<details>
+<summary>View Answer</summary>
+
+## Correct Answer
+D
+
+## Explanation
+1. Diagnostic Assessment:
+   - Confirmed hypercortisolism:
+     * Elevated UFC
+     * Failed overnight DST
+     * Elevated midnight cortisol
+   - ACTH-dependent Cushing's:
+     * ACTH >20 pg/mL rules out primary adrenal
+     * Suggests pituitary or ectopic source
+
+2. Next Step Rationale:
+   - IPSS indicated because:
+     * Need to differentiate pituitary from ectopic
+     * ACTH in intermediate range (>20 but <100)
+     * High stakes decision for surgery
+     * Most accurate test for source localization
+
+3. Why Other Options Wrong:
+   - Option A:
+     * MRI alone insufficient
+     * Many incidental adenomas
+     * Can miss small tumors
+
+   - Option B:
+     * Less accurate than IPSS
+     * Won't definitively locate source
+
+   - Option C:
+     * Lower accuracy than IPSS
+     * Won't change management
+
+   - Option E:
+     * Premature without ACTH source confirmation
+     * Unnecessary radiation if pituitary source
+
+## References
+- Endocrine Society Guidelines 2023
+- NEJM 2022: "Cushing's Syndrome Diagnosis"
+- J Clin Endocrinol Metab 2021
+
+## Teaching Points
+1. Diagnostic algorithm
+2. Test interpretation
+3. Source localization
+4. Imaging limitations
+5. Treatment planning
+</details>

questions/endocrinology/diabetes/diabetic-foot.md

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+---
+id: ENDO007
+specialty: endocrinology
+topic: diabetes
+difficulty: medium
+tags: [endocrine, infections, treatment, chronicCare, copilot]
+created: 2025-01-06
+lastUpdated: 2025-01-06
+---
+
+# Diabetic Foot Infection Management
+
+## Question
+A 58-year-old man with type 2 diabetes (HbA1c 8.9%) presents with:
+- 2-week history of right foot ulcer
+- Worsening pain and redness
+- Moderate drainage
+- No fever
+
+Examination shows:
+- 3cm x 2cm ulcer over plantar surface
+- Probing to bone
+- Surrounding erythema 2cm
+- Pedal pulses present
+- Normal temperature
+
+Labs:
+- WBC: 11,200/µL
+- ESR: 55 mm/hr
+- CRP: 4.2 mg/dL
+- Creatinine: 1.1 mg/dL
+
+Foot X-ray shows no osteomyelitis.
+
+Which initial management is most appropriate?
+
+## Options
+| Option | Description |
+|--------|-------------|
+| A)     | Oral amoxicillin-clavulanate + wound care |
+| B)     | Hospital admission + IV vancomycin |
+| C)     | MRI foot + bone biopsy |
+| D)     | Amputation |
+| E)     | Topical antibiotics only |
+
+<details>
+<summary>View Answer</summary>
+
+## Correct Answer
+A
+
+## Explanation
+1. Assessment:
+   - Moderate infection:
+     * Local inflammation
+     * No systemic signs
+     * Probing to bone but negative X-ray
+     * Intact circulation
+
+2. Treatment Rationale:
+   - Outpatient management appropriate:
+     * No sepsis
+     * No deep tissue involvement
+     * Good blood supply
+     * Patient stable
+
+   - Oral antibiotics sufficient:
+     * Broad spectrum coverage needed
+     * Common pathogens covered
+     * Good tissue penetration
+     * Can be modified based on culture
+
+3. Why Other Options Wrong:
+   - Option B:
+     * Too aggressive
+     * No indication for IV therapy
+     * Unnecessary hospitalization
+
+   - Option C:
+     * Not indicated without X-ray changes
+     * Can consider if no improvement
+
+   - Option D:
+     * Far too aggressive
+     * No tissue necrosis
+     * Good blood supply
+
+   - Option E:
+     * Insufficient coverage
+     * Won't prevent progression
+
+## References
+- IDSA Guidelines 2022: "Diabetic Foot Infections"
+- ADA Standards of Care 2023
+
+## Teaching Points
+1. Infection severity assessment
+2. Antibiotic selection principles
+3. Role of imaging
+4. Indications for hospitalization
+5. Follow-up monitoring
+</details>

questions/endocrinology/diabetes/dka-management.md

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+---
+id: ENDO004
+specialty: endocrinology
+topic: diabetes
+difficulty: hard
+tags: [endocrine, emergencies, criticalCare, acidBase, electrolytes, claude35Sonnet]
+created: 2025-01-06
+lastUpdated: 2025-01-06
+---
+
+# Complex DKA Management
+
+## Question
+A 25-year-old woman with type 1 diabetes presents with:
+- Severe abdominal pain
+- Vomiting for 24 hours
+- Altered mental status
+
+Initial labs:
+- Glucose: 680 mg/dL (37.8 mmol/L)
+- pH: 6.95
+- Bicarbonate: 5 mEq/L
+- Anion gap: 32
+- Na: 128 mEq/L
+- K: 5.8 mEq/L
+- BUN: 48 mg/dL
+- Serum osmolality: 328 mOsm/kg
+
+After 6 hours of standard DKA protocol:
+- Glucose: 240 mg/dL (13.3 mmol/L)
+- Persistent acidosis (pH 7.10)
+- Worsening mental status
+- New focal neurologic deficits
+
+Which immediate intervention is most appropriate?
+
+## Options
+| Option | Description |
+|--------|-------------|
+| A)     | Increase insulin drip rate + continue current fluids |
+| B)     | Emergent head CT + mannitol + hypertonic saline |
+| C)     | Switch to subcutaneous insulin + oral hydration |
+| D)     | Add bicarbonate infusion + increase fluid rate |
+| E)     | Decrease dextrose concentration in IV fluids |
+
+<details>
+<summary>View Answer</summary>
+
+## Correct Answer
+B
+
+## Explanation
+1. Clinical Assessment:
+   - Initial severe DKA with:
+     * Profound acidosis
+     * Significant hyperglycemia
+     * High osmolality
+   - Concerning development:
+     * Rapid glucose correction
+     * New neurologic deficits
+     * Mental status changes
+     * Suggests cerebral edema
+
+2. Management Priority:
+   - Cerebral edema is life-threatening:
+     * 20-40% mortality
+     * Requires immediate intervention
+     * Diagnostic imaging crucial
+   - Osmotic therapy:
+     * Mannitol reduces ICP
+     * Hypertonic saline stabilizes osmolality
+     * Time-sensitive intervention
+
+3. Why Other Options Fail:
+   - Option A:
+     * May worsen cerebral edema
+     * Doesn't address neurologic deterioration
+
+   - Option C:
+     * Inappropriate during acute crisis
+     * Dangerous in cerebral edema
+
+   - Option D:
+     * Bicarbonate controversial in DKA
+     * Won't address cerebral edema
+
+   - Option E:
+     * Secondary concern
+     * Delays critical intervention
+
+## References
+- NEJM 2022: "DKA Management Updates"
+- Pediatric Critical Care 2021: "Cerebral Edema in DKA"
+- Endocrine Society Guidelines 2023
+
+## Teaching Points
+1. Recognition of cerebral edema
+2. Rapid intervention importance
+3. Osmotic therapy principles
+4. Monitoring complications
+5. Prevention strategies
+</details>