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36 Cards in this Set

  • Front
  • Back
Glucose abnormalities/Diabetes
Psychological changes
Hypertension
Bone loss/Osteoporosis
Obesity (central)
Proximal muscle weakness

are signs of?
Cortisol excess (Cushing's syndrome)

also:
Weight gain (80-97%)
Moon facies (75%)
Proximal muscle weakness/wasting (61%)
Striae (reddish-purple >1 cm (66%)
Plethora (60%)
Compression fractures (22%)
Liddle’s sign: paper-thin skin on dorsum of hand
4 causes of cushing syndrome (cortisol excess)
Iatrogenic is most common - history of glucocorticoid use

Cushing’s Disease (pituitary tumor)

Ectopic A.C.T.H. (small cell lung cancer)

Adrenal Tumor
describe ACTH independent cushing syndrome..cause?
ACTH is low or zero

comes from cortisol producing adrenal tumor
possible causes of ACTH dependent cushings?
ACTH secreting pituitary tumor

Ectopic ACTH
in ectopic ACTH causing Cushing syndrome, what can you see in up to 10% of cases?

*in red, but he didn't really say anything about it
Can see unrelated tumors in pituitary in up to 10% of cases
again, what were the 2 tests for Cushing syndrome? levels?
24 hour free urine

Dexamethasone Suppression test
Level <5 ug/dL rules out Cushing’s
Level >10 ug/dL is highly suggestive
Dexamethasone levels showing cushings?
Level <5 ug/dL rules out Cushing’s
Level >10 ug/dL is highly suggestive
Once Cushing’s is established, the next step is to determine whether it is ACTH-Dependent or ACTH-Independent. When you measure, what levels show each?
<5 pg/ml in ACTH-independent
>20 pg/ml in ACTH-dependent
how can you tell the difference btw pituitary secreting ACTH or ectopic?
pituitary can be suppressed with high dose steroids...ectopic cannot (on dexamethasone suppression test)
when you do surgery for ectopic ACTH producing tumors what must you do first?
Remember to start replacement before surgery.

because their values will be off
26 year old woman comes to your office for complaints of weight gain, plethora, Buffalo hump, proximal muscle weakness and amenorrhea. You note hypertension, hyperglycemia and hirsuitism. Which of the following studies would be most appropriate to order at this time?
A. MRI of the brain with special attention to the pituitary
B. Morning and afternoon cortisol levels
C. 24-hour urinary free cortisol
D. Morning cortisol and ACTH level
C. 24-hour urinary free cortisol

(other option would have been low dose dexamethasone suppression test)
What are some of the clinical manifestations of adrenal insufficiency?
Fatigue and weakness (95%)
Anorexia (90%)
Weight loss (100%)
Impaired mentation (75%)
most common infectious cause of adrenal insufficiency?
TB

(others: fungal, HIV)
What is Addison's Disease?
Autoimmune Adrenal Insufficiency (80% of all primary adrenal insufficiency).

Can be associated with Polyendocrine Autoimmune Syndrome.

Type 1 includes mucocutaneous candidiasis, hypoparathyroidism, gonadal failure, pernicious anemia, Hashimoto;s thyroiditis, autosomal recessive or sporatic.

Type 2 include Type 1 DM, Hashimoto’s, Grave’s, gonadal failure, autosomal dominant.
Salt craving
Hyperpigmetation
Hyperkalemia

are findings of what?
Addison's disease
what is mineralocorticoid function like in secondary adrenal insufficiency?
Mineralocorticoid function is intact
do not see associated hyperkalemia
If only primary adrenal insufficiency is suspected, do ACTH, what should the levels be?
> 100 pg/mL.
what is the Cosyntropin (ACTH) Stimulation Test?
250 ug injected IM or IV
Cortisol levels are measured at 0, 30 and 60 minutes.
Normal response is a rise in cortisol to > 20 ug/dl.

if it doesn't go above 20 then you have adrenal insufficiency

Sensitivity
97% for primary adrenal insufficiency.
57% for secondary adrenal insufficiency.
tx for adrenal insufficiency (primary)
Glucocorticoid replacement
Hydrocortisone or Prednisone

Mineralocorticoid replacement (primary only)
Fludrocortisone (Florinef)
24 year old man presents with fatigue, weight loss and dizziness. His glucoses are normal/low. Sodium low and potassium slightly high. You suspect adrenal insufficiency. Which test would be most appropriate?
A. AM cortisol and ACTH
B. Cosyntropin (ACTH) stimulation test
C. 24-hour urinary cortisol
B. Cosyntropin (ACTH) stimulation test
if you have an adrenal incidentaloma, at what size do you consider surgery? What MUST you rule out before surgery?

***red
if > 4 cm consider removal

ALWAYS RULE OUT PHEOCHROMOCYTOMA BEFORE SURGERY
66 year old woman is hospitalized for abdominal pain. A C.T. scan reveals a 3 cm solid mass in the right adrenal gland. She is obese and has diabetes and hypertension. What do you recommend?

A. Consult a surgeon to remove the mass.
B. Obtain appropriate studies to asses function
C. Repeat CT at a later date
B. Obtain appropriate studies to asses function

(this is the initial thing to do, you would want to repeat the CT later)
clinical manifestations of hyperaldosteronism?
Hypertension
Hypokalemia
cause of primary hyperaldosteronism? Renin levels?
Caused by adrenal adenoma or bilateral adrenal hyperplasia
High aldosterone despite fluids and sodium
Low plasma renin activity despite fluid depletion or postural changes.
aldosterone:renin of 20:1 is most likely?
primary hyperaldosteronism
renin levels in secondary hyperaldosteronism?
High
Episodes of headache, tachycardia, diaphoresis, anxiety, or chest pain/pressure
Hypertension (higher with episodes)
“Spells”

associated with?
Pheochromocytoma
best diagnostic test for Pheochromocytoma?
24 hour metanephrines, catecholamines and/or VMA
best way to image a pheochromocytoma?
MRI
what is the rule of 10s? associated with?
associated with pheochromocytoma

10% in kids
10% bilateral
extra-adrenal
maligant
calcify
familia
what are the 5 Ps of pheochromocytoma?
pressure (increased BP)
pain (headache)
perspiration
palpitations (tachy)
pallor
prior to surgery, what must a pheochromocytoma pt be pre-treated with?

***red
The patient must be pretreated with Alpha blocker prior to surgery. Phenoxybenzamine is most commonly used.
A patient presents with “spells” characterized
by tachycardia, chest tightness and episodic
severe headaches. Blood pressure has been
high and difficult to control. What test(s) would
you order?

C.T. or MRI of adrenals?
24hour urine for metanephrines?
Plasma catecholamines?
24hour urine for metanephrines
DHEA is the principle androgen secreted by the adrenal gland... what levels suggest adrenal tumor?
DHEA-S >700 suggests adrenal tumor
Testosterone is the principle androgen from the gonads. levels of what suggest an ovarian tumor?
>200 in females suggest ovarian tumor
Every patient with Cortisol Deficiency has what 2 symptoms?
Weight loss

Hyponatremia +/- hyperkalemia