Thyroid, Adrenal, Pituitary and Parathyroid Disorders for NEET PG Medicine: ICMR Hypothyroidism, Graves, Cushing, Addison

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🎯 Exam priority: High. Expect: overt vs subclinical vs central hypothyroidism, levothyroxine dose and elderly start, titrating central hypothyroidism by FT4, myxoedema coma, Graves features and TSI, PTU vs methimazole, agranulocytosis, thyroid storm triggers, Cushing tests and causes, Addison electrolytes and crisis, Conn and phaeochromocytoma, prolactinoma drug, hypopituitarism order, Sheehan, DI and hyperparathyroidism types.

CBME mapping: GM 12.1–12.14 (thyroid) with adrenal and pituitary topics. Endocrine pathology is in Pathology article 26; drugs in Pharmacology; diabetes in article 17; calcium disorders also in article 16.

Adrenal and pituitary syndromes, ICMR hypothyroidism, Graves disease and parathyroid. Drawn by TrackNation.

Hypothyroidism

• Symptoms: fatigue, weight gain with poor appetite, cold intolerance, dry skin, constipation, hoarseness, menorrhagia, infertility; signs — puffy face, bradycardia, delayed tendon-reflex relaxation, carpal tunnel syndrome, effusions. Billewicz score: ≥ 6 hypothyroid, 3–5 intermediate, ≤ 2 euthyroid.

• Commonest cause (MSD): autoimmune — Hashimoto thyroiditis (lymphocytic infiltration, high anti-TPO, painless goitre; rarely thyroid lymphoma). Iodine deficiency causes endemic goitre.

• Treat subclinical disease with a large goitre, positive TPO antibodies, ASCVD, heart failure, infertility, dyslipidaemia or TSH > 10 (high progression risk). Target TSH in the young 1–2.5 mU/L, higher with age.

• Myxoedema coma: coma with extreme hypothermia in long-standing hypothyroidism — IV T4 plus glucocorticoids and support.

Hyperthyroidism

• Commonest causes: Graves disease, multinodular goitre, toxic nodule, thyroiditis. Graves: a stimulating autoantibody (TSI) to the TSH receptor; goitre, exophthalmos, infiltrative dermopathy (pretibial myxoedema).

• Treatment: methimazole or PTU, beta-blockers for symptoms, iodine, radioactive iodine, thyroidectomy. Thionamides: rash, liver injury (liver failure with PTU), agranulocytosis in ~0.1%. PTU only in special situations — first trimester of pregnancy and thyroid storm.

• Thyroid storm: life-threatening acute hyperthyroidism in untreated/undertreated Graves or toxic MNG, triggered by infection, trauma, surgery, DKA or pre-eclampsia.

• hCG peaks in the first trimester and can lower TSH physiologically. Nodules: ultrasound features decide fine-needle aspiration.

Adrenal Disorders

• Cushing syndrome: moon face, buffalo hump, striae, thin limbs. ACTH-dependent — pituitary tumour (Cushing disease) or ectopic ACTH (small cell lung cancer); ACTH-independent — therapeutic glucocorticoids, adrenal adenoma/carcinoma. Tests: urinary free cortisol, dexamethasone suppression, midnight serum/salivary cortisol, then ACTH.

• Addison disease: mostly autoimmune; also TB and other granulomas. Hypotension, hyperpigmentation, hyponatraemia, hyperkalaemia. High ACTH with low cortisol. Treat with hydrocortisone + fludrocortisone. Adrenal crisis: give hydrocortisone at once — delay for testing may be fatal.

• Primary aldosteronism: hypertension, hypokalaemia, weakness; measure aldosterone and renin; remove an adenoma; spironolactone for hyperplasia.

• Phaeochromocytoma: severe headache, sweating, palpitations, paroxysmal hypertension; plasma or urine metanephrines; alpha-blockade first, then beta-blockers, then surgery. Bilateral in 10% (20% in children), malignant in ~10%.

Pituitary and Parathyroid

• Prolactinoma: galactorrhoea commonest; most in women are microadenomas (< 10 mm). Cabergoline is preferred over bromocriptine.

• Acromegaly: GH drives IGF-1 (measure it); surgery is first-line; octreotide/lanreotide if surgery is not possible.

• Hypopituitarism: GH is lost first, then gonadotropins, then TSH and ACTH. Causes include pituitary apoplexy and Sheehan syndrome (postpartum shock).

• Central DI: polyuria, polydipsia; water deprivation test fails to concentrate urine; desmopressin. Nephrogenic DI is AVP resistance.

• Hyperparathyroidism: primary — usually a single adenoma, often asymptomatic hypercalcaemia, kidney stones; parathyroidectomy cures. Secondary — response to hypocalcaemia (e.g. CKD). Tertiary — autonomous PTH after long secondary disease.

Traps the Examiner Sets

• Central hypothyroidism: TSH is unreliable — follow FT4; give hydrocortisone before LT4 if adrenal deficit.

• PTU in the first trimester and in thyroid storm; methimazole otherwise.

• Phaeochromocytoma: never start a beta-blocker before alpha-blockade.

• Suspected adrenal crisis: hydrocortisone first, tests later.

• Hypopituitarism: GH first, ACTH last.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 Central hypothyroid: 'Follow the Free T4, Forget the TSH' — central hypothyroidism

• 🧠 'Steroids before thyroid' when the adrenals are weak — replacement order

• 🧠 PTU = 'Pregnancy (1st trimester) and Thyroid storm Use' — PTU

• 🧠 Phaeo: 'Alpha before Beta' as in the alphabet — phaeochromocytoma

• 🧠 Hypopituitarism 'Go Look For The Adenoma': GH, LH/FSH, TSH, ACTH — hormone loss order

• 🧠 Cabergoline: 'Cab-ride beats the Bromo-bus' — prolactinoma

Rapid-Revision Cards

• Overt vs subclinical

  TSH ↑ + low FT4 vs TSH ↑ + normal FT4.

• Central hypothyroidism

  Low FT4 with normal/low TSH; follow FT4.

• LT4 dose

  1.6–1.8 µg/kg/day; elderly/CAD 12.5–25 µg.

• Adrenal + thyroid deficit

  Hydrocortisone before LT4.

• Congenital screen

  After 72 h; TSH > 30.

• Billewicz

  ≥ 6 hypothyroid.

• Hashimoto

  Anti-TPO; lymphocytes; rarely lymphoma.

• Myxoedema coma

  IV T4 + steroids.

• Graves

  Stimulating TSI; exophthalmos; pretibial myxoedema.

• PTU uses

  1st trimester, thyroid storm.

• Thionamide danger

  Agranulocytosis ~0.1%; PTU liver failure.

• Storm triggers

  Infection, trauma, surgery, DKA.

• Cushing disease

  Pituitary ACTH tumour.

• Cushing tests

  UFC, dexamethasone suppression, night cortisol.

• Addison

  Pigmentation, ↓Na ↑K, high ACTH low cortisol.

• Adrenal crisis

  Hydrocortisone now.

• Conn

  HTN + low K; aldosterone/renin.

• Phaeo

  Metanephrines; α then β.

• Phaeo 10s

  10% bilateral, 10% malignant.

• Prolactinoma

  Cabergoline.

• Acromegaly

  IGF-1; surgery first.

• Hypopituitarism order

  GH → LH/FSH → TSH, ACTH.

• Sheehan

  Postpartum haemorrhage → pituitary infarct.

• Central DI

  Water deprivation; desmopressin.

• Hyperparathyroidism

  1° adenoma; 2° low Ca; 3° autonomous.

Sources

Facts in this article were checked against these documents.

• Standard Treatment Workflow: Hypothyroidism — Indian Council of Medical Research, DHR, 2022 (link)

• MSD Manual Professional: Hypothyroidism; Hashimoto Thyroiditis; Hyperthyroidism; Thyroid Nodule; Cushing Syndrome; Primary Adrenal Insufficiency; Primary Aldosteronism; Pheochromocytoma; Prolactinoma; Gigantism and Acromegaly; Generalized Hypopituitarism; Central Diabetes Insipidus; Hyperparathyroidism — Merck & Co. (MSD Manuals), reviewed 2025–26 (link)

• Competency Based Undergraduate Curriculum, General Medicine (GM 12) — National Medical Commission, 2024

Test Yourself: Practice Questions

Thirty questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. A woman has fatigue, weight gain, cold intolerance and constipation; TSH is high and free T4 low. The diagnosis is

• (a) central hypothyroidism

• (b) subclinical hypothyroidism

• (c) Graves disease

• (d) overt primary hypothyroidism

Q2. TSH is raised with a normal free T4 in a minimally symptomatic person. This is

• (a) central hypothyroidism

• (b) subclinical hypothyroidism

• (c) overt hypothyroidism

• (d) euthyroid sick syndrome

Q3. A patient with a pituitary macroadenoma has low free T4 with a normal TSH. This indicates

• (a) laboratory error

• (b) hyperthyroidism

• (c) central (secondary) hypothyroidism — titrate levothyroxine by FT4

• (d) primary hypothyroidism — titrate by TSH

Q4. The usual full replacement dose of levothyroxine for a young adult with primary hypothyroidism per ICMR is

• (a) 10–15 µg/kg/day

• (b) 1.6–1.8 µg/kg/day on an empty stomach

• (c) 0.5 µg/kg/day

• (d) 200 µg weekly

Q5. A 74-year-old with coronary artery disease is newly found to have hypothyroidism. Levothyroxine should be started at

• (a) 1.8 µg/kg/day at once

• (b) only after angiography

• (c) 200 µg/day

• (d) 12.5–25 µg/day, increased every 3–4 weeks

Q6. A patient with hypopituitarism has both central hypothyroidism and adrenal insufficiency. Before levothyroxine, give

• (a) growth hormone

• (b) fludrocortisone alone

• (c) nothing

• (d) hydrocortisone

Q7. On newborn screening for congenital hypothyroidism (ICMR), the screening TSH cut-off is

• (a) not done in India

• (b) > 100 mU/L only

• (c) > 5 mU/L at birth

• (d) > 30 mU/L, tested after 72 hours

Q8. The Billewicz score in suspected hypothyroidism classifies as hypothyroid a total of

• (a) 6 points or more

• (b) 3–5 points

• (c) 12 points only

• (d) 2 points or less

Q9. A woman has a painless firm goitre, hypothyroidism and high anti-TPO antibody titres. The diagnosis is

• (a) Hashimoto thyroiditis

• (b) thyroid cancer

• (c) subacute thyroiditis

• (d) Graves disease

Q10. A long-standing hypothyroid patient is found comatose with extreme hypothermia. Treatment is

• (a) oral levothyroxine 25 µg

• (b) propylthiouracil

• (c) IV T4 plus glucocorticoids and supportive care

• (d) rapid external rewarming only

Q11. A woman with hyperthyroidism has goitre, proptosis and non-pitting swelling over the shins. The antibody responsible is

• (a) a stimulating antibody against the TSH receptor (TSI)

• (b) anti-thyroglobulin inhibiting the gland

• (c) anti-TPO causing destruction

• (d) anti-GAD

Q12. A woman in the first trimester of pregnancy has Graves hyperthyroidism. The preferred antithyroid drug then is

• (a) radioactive iodine

• (b) propylthiouracil

• (c) lugol iodine alone

• (d) methimazole

Q13. A patient on methimazole develops fever and sore throat. The dangerous adverse effect to exclude is

• (a) hypothyroidism

• (b) hyperkalaemia

• (c) agranulocytosis

• (d) lactic acidosis

Q14. Thyroid storm is commonly precipitated by

• (a) levothyroxine overdose only

• (b) iodine deficiency

• (c) infection, trauma or surgery in poorly controlled hyperthyroidism

• (d) hypothermia

Q15. In early pregnancy a mildly low TSH with slightly high free T4 may be due to

• (a) hypopituitarism

• (b) high hCG, a weak thyroid stimulator, peaking in the first trimester

• (c) Graves disease always

• (d) lab error

Q16. Cushing disease specifically means

• (a) Cushing syndrome due to an ACTH-secreting pituitary tumour

• (b) any steroid excess

• (c) adrenal carcinoma

• (d) ectopic ACTH from lung cancer

Q17. A screening test for Cushing syndrome is

• (a) glucagon test

• (b) ACTH stimulation test

• (c) water deprivation test

• (d) overnight dexamethasone suppression test

Q18. A patient has weakness, postural hypotension, skin pigmentation, Na 126 and K 5.9 mmol/L. The likely diagnosis is

• (a) primary adrenal insufficiency (Addison disease)

• (b) Conn syndrome

• (c) Cushing syndrome

• (d) SIADH

Q19. Besides autoimmunity, an important destructive cause of Addison disease is

• (a) iodine deficiency

• (b) hepatitis A

• (c) tuberculosis

• (d) thiazides

Q20. A patient arrives in shock with suspected adrenal crisis. The first step is

• (a) give hydrocortisone immediately — do not wait for tests

• (b) do an ACTH stimulation test first

• (c) give insulin

• (d) start fludrocortisone only

Q21. Long-term replacement in Addison disease is

• (a) dexamethasone alone

• (b) hydrocortisone plus fludrocortisone

• (c) fludrocortisone alone

• (d) spironolactone

Q22. A patient has hypertension, episodic muscle weakness and low potassium. The screening tests are

• (a) TSH

• (b) plasma aldosterone and renin activity

• (c) metanephrines

• (d) serum cortisol

Q23. A patient has episodes of severe headache, sweating and palpitations with very high blood pressure. The first test is

• (a) serum aldosterone

• (b) plasma free or urinary metanephrines

• (c) dexamethasone suppression

• (d) ACTH stimulation

Q24. Before surgery for phaeochromocytoma, blood pressure is controlled with

• (a) alpha-blockers first, then beta-blockers

• (b) diuretics

• (c) ACE inhibitors alone

• (d) beta-blockers first

Q25. A woman with galactorrhoea and amenorrhoea has a 6 mm pituitary prolactinoma. The treatment of choice is

• (a) bromocriptine always

• (b) cabergoline

• (c) radiotherapy

• (d) surgery first

Q26. First-line treatment for most patients with acromegaly is

• (a) surgical removal of the pituitary tumour

• (b) octreotide for life

• (c) cabergoline

• (d) radiotherapy

Q27. After shock from postpartum haemorrhage, a woman develops features of pituitary hormone deficiency. The diagnosis is

• (a) prolactinoma

• (b) Sheehan syndrome

• (c) Cushing disease

• (d) Asherman syndrome

Q28. In hypopituitarism, the hormone most commonly lost first is

• (a) vasopressin

• (b) ACTH

• (c) growth hormone

• (d) TSH

Q29. A patient with polyuria and polydipsia cannot concentrate urine on a water deprivation test but responds to vasopressin. Treatment is

• (a) insulin

• (b) thiazide only (nephrogenic DI)

• (c) desmopressin (central DI)

• (d) fluid restriction

Q30. The commonest cause of primary hyperparathyroidism is

• (a) CKD

• (b) vitamin D deficiency

• (c) parathyroid carcinoma

• (d) a single parathyroid adenoma

Active Recall

From memory: distinguish overt, subclinical and central hypothyroidism and give the ICMR levothyroxine dosing rules, describe Graves disease and antithyroid drug cautions, thyroid storm and myxoedema coma, and outline diagnosis and treatment of Cushing, Addison, Conn, phaeochromocytoma, prolactinoma, acromegaly, hypopituitarism, central DI and hyperparathyroidism.