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Addison’s Disease & Adrenal Anatomy: High-Yield MCQs for MSRA Success

Updated: Jul 4

Question 1

A 45-year-old woman presents with fatigue, weight loss, and craving for salty foods. Examination reveals hyperpigmentation of the palmar creases and buccal mucosa. Her blood pressure is 88/60 mmHg lying and drops to 70/50 mmHg on standing. Blood tests show Na⁺ 128 mmol/L, K⁺ 5.8 mmol/L.

Which is the most likely underlying pathology?

Choose the correct answer

  • A) Autoimmune destruction of adrenal medulla

  • B) Autoimmune destruction of adrenal cortex

  • C) Pituitary ACTH deficiency

  • D) Aldosterone-secreting adrenal adenoma

Answer: B) Autoimmune destruction of adrenal cortex

🗝️ Clinchers: Fatigue + weight loss + salt craving + hyperpigmentation + hyponatremia + hyperkalemia → Addison’s (primary adrenal insufficiency).



Question 2

Which hormone is not ACTH dependent?

Choose the correct answer

  • A) Cortisol

  • B) Aldosterone

  • C) DHEA

  • D) Androstenedione

Answer: B) Aldosterone

🗝️ Clinchers: Zona glomerulosa produces aldosterone → regulated by RAAS & potassium, not ACTH.



Question 3

A 30-year-old man presents with vomiting, severe abdominal pain, and hypotension. His sodium is 126 mmol/L and potassium 6.2 mmol/L. Cortisol is 80 nmol/L at 8 AM. What is the next best step?

Choose the correct answer

  • A) Repeat cortisol next morning

  • B) Start IV hydrocortisone and IV fluids immediately

  • C) Start fludrocortisone alone

  • D) Arrange outpatient Synacthen test

Answer: B) Start IV hydrocortisone and IV fluids immediately

🗝️ Clinchers: Suspected adrenal crisis → treat immediately without waiting for confirmatory tests.



Question 4

Which of the following is correct regarding adrenal cortical zones?

Choose the correct answer

  • A) Zona fasciculata produces mineralocorticoids

  • B) Zona glomerulosa produces glucocorticoids

  • C) Zona reticularis produces androgens

  • D) Medulla produces mineralocorticoids

Answer: C) Zona reticularis produces androgens

🗝️ Mnemonic: GFR – Salt, Sugar, Sex → Glomerulosa (aldosterone), Fasciculata (cortisol), Reticularis (androgens).



Question 5

Regarding the Synacthen test, which of the following is correct?

Choose the correct answer

  • A) Uses 50 μg tetracosactide administered IM

  • B) Measures cortisol at 0, 15, and 60 minutes

  • C) Cortisol >500 nmol/L post stimulation rules out adrenal i

  • D) Cannot be performed in the afternoon

Answer: C) Cortisol >500 nmol/L post stimulation rules out adrenal insufficiency

🗝️ Clinchers: Standard 250 μg Synacthen test, measure at 0 and 30 mins, can be performed any time of day.


Why not Option E as the best answer?

Synacthen test alone cannot conclusively differentiate secondary AI because:

In early secondary AI, adrenals respond normally.

In chronic secondary AI, adrenals may atrophy and show poor response similar to primary AI.



Question 6

In Addison’s disease, which electrolyte disturbance is least common?

Choose the correct answer

  • A) Hyponatremia

  • B) Hyperkalemia

  • C) Hypoglycemia

  • D) Hypercalcemia

Answer: E) Hypernatremia

🗝️ Clinchers: Addison’s → hyponatremia, hyperkalemia, hypoglycemia, mild hypercalcemia (10-20%). Hypernatremia is not typical.



Question 7

Which of the following syndromes is correctly matched?

Choose the correct answer

  • A)Schmidt’s syndrome– Addison’s + hypoparathyroidism + T1DM

  • B)APECED– Addison’s + autoimmune thyroid disease ± T1DM

  • D)APECED– Addison’s + autoimmune thyroid disease ± T2DM

  • E)Schmidt’s syndrome– Addison’s+hypoparathyroidism+candidias

Answer: C) Schmidt’s syndrome – Addison’s + autoimmune thyroid disease ± Type 1 DM

🗝️ Clinchers:

  • APS Type 1 (APECED): Addison’s + hypoparathyroidism + candidiasis

  • APS Type 2 (Schmidt’s): Addison’s + autoimmune thyroid ± T1DM




Question 8

A patient with suspected Addison’s disease has an 8 AM serum cortisol of 120 nmol/L. What is the most appropriate next investigation?

Choose the correct answer

  • A) Start fludrocortisone immediately

  • B) Plasma ACTH level

  • C) Synacthen stimulation test

  • D) Random cortisol level

Answer: C) Synacthen stimulation test

🗝️ Clinchers: Cortisol 100–500 nmol/L → indeterminate → needs ACTH stimulation test.



Question 9

Which of the following clinical features is specific for primary adrenal insufficiency (Addison’s disease) but not for secondary adrenal insufficiency?

Choose the correct answer

  • A) Hyponatremia

  • B) Hypoglycemia

  • C) Hyperkalemia

  • D) Hypotension

Answer: C) Hyperkalemia

🗝️ Clinchers: Hyperkalemia due to lack of aldosterone (only in primary). Secondary AI spares aldosterone.



Question 10

A 35-year-old man with a history of tuberculosis presents with hypotension, hyperpigmentation, and weight loss. Blood tests show Na⁺ 127 mmol/L and K⁺ 6.0 mmol/L. What would you expect his ACTH level to be?

Choose the correct answer

  • A) Low

  • B) Normal

  • C) High

  • D) Undetectable

Answer: C) High

🗝️ Clinchers: Primary AI → low cortisol → loss of negative feedback → high ACTH.



Question 11

Which of the following statements about adrenal medulla is correct?

Choose the correct answer

  • A) Produces steroid hormones

  • B) Stimulated by ACTH

  • C) Produces catecholamines under parasympathetic stimulation

  • D)Stimulated by preganglionic sympathetic fibres release ACh

Answer: D) Stimulated by preganglionic sympathetic fibres releasing ACh

🗝️ Clinchers: Medulla = chromaffin cells = modified sympathetic ganglia → produce epinephrine/norepinephrine.



Question 12

Which test is used to confirm the diagnosis of Addison’s disease?

Choose the correct answer

  • A) Overnight dexamethasone suppression test

  • B) Synacthen (ACTH stimulation) test

  • C) Low-dose dexamethasone suppression test

  • D) Plasma renin activity

Answer: B) Synacthen (ACTH stimulation) test

🗝️ Clinchers: Synacthen test confirms adrenal insufficiency, differentiates primary vs secondary AI by ACTH and cortisol interpretation.



Question 13

A patient with Addison’s disease is planning a strenuous trekking trip. What should be advised?

Choose the correct answer

  • A) No change in steroid dosing

  • B) Halve their usual hydrocortisone dose

  • C) Double both glucocorticoid and mineralocorticoid doses

  • D) Stop fludrocortisone for the day

Answer: C) Double both glucocorticoid and mineralocorticoid doses

🗝️ Clinchers: During strenuous exercise, stress dosing applies to both hydrocortisone and fludrocortisone.



Question 14

Which electrolyte abnormality is seen in ~10-20% of patients with Addison’s disease?

Choose the correct answer

  • A) Hypocalcemia

  • B) Hypercalcemia

  • C) Hypernatremia

  • D) Hypokalemia

Answer: B) Hypercalcemia

🗝️ Clinchers: Mild hypercalcemia (10-20%) due to haemoconcentration and increased calcium reabsorption.



Question 15

A 50-year-old woman presents with fatigue, nausea, postural dizziness, and skin hyperpigmentation. She is diagnosed with Addison’s disease. Which autoantibody is most likely to be positive?

Choose the correct answer

  • A) Anti-thyroid peroxidase

  • B) Anti-GAD

  • C) Anti-21 hydroxylase

  • D) Anti-TSH receptor

Answer: C) Anti-21 hydroxylase

🗝️ Clinchers: Autoimmune adrenalitis → anti-21 hydroxylase antibodies (>80% cases).


⭐ Rapid Recap:

  • Primary AI: Hyperkalemia, high ACTH, hyperpigmentation.

  • Synacthen test: Confirms diagnosis.

  • Medulla: Produces catecholamines under sympathetic cholinergic stimulation.

  • Stress dosing: Double steroids during illness, strenuous activity.

  • GFR mnemonic: Salt (aldosterone), Sugar (cortisol), Sex (androgens)

  • Addison’s: Hyperpigmentation + salt craving + hypotension + hyponatremia + hyperkalemia

  • Synacthen test: >500 nmol/L excludes AI

  • Adrenal crisis: Treat with IV hydrocortisone + fluids urgently

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