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46 Cards in this Set

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37 year old, fatigue, weakness, "charley horses", if she got up to quick she felt like she was going to fall and pass out, in fact she did when she got out of bed this morning. Also she has cramps, dizzy spells, stopped having menstrual cycles. Thyroid was smooth, diffusely enlarged. Tanned appearance, "freckling" of the buccal mucosa, biatch says she craves salt.
Addison's disease
What times should you measure cortisol?
8am

and between 11-12 at night
if you suspect Addison's disease, what blood test must you order? how does it work

***TEST
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. (or double from base number***)

if it doesn't go above 20 then you have adrenal insufficiency
if you have both Addisons and thyroid disease, which one should you treat first?
try and take care of the Addison's first and see if the thyroid corrects
What are some of the things that can mess up a Cosyntropin (ACTH) Stimulation Test
DHEA, estrogen, spironolactone
What is the most likely underlying cause of Addisons in the US?

sarcoidosis
tuberculosis
autoimmune
invasive carcinoma
meningococcal septicemia
autoimmune--most common cause in US

other countries--TB
Effects of glucorticoids? (what do they do)
gluconeogenesis
immune suppression
anti-inflammatory
BP affects
what do mineralcorticoids do?
water management
Primary adrenal insufficiency is also known as? what is affected?
Addison's

adrenal cortex
Where does secondary adrenal insufficiency occur? what is happening?
Pituitary

not secreting enough ACTH

caused by: infarct, adenoma, aneurysm, surgery, congenital
most common cause of secondary hypocorticolism (adrenal insufficiency)?
Taking a person off exogenous steroids quickly
where does tertiary hypocorticolism occur? what is going on?
Hypothalamus

decrease in CRH (and resulting ACTH and cortisol)
hypoglycemia is more common in primary or secondary adrenal insufficiency?
SECONDARY
Which of the following suggests a primary adrenal insufficiency rather than secondary?
Hyperpigmentation

(also you will have effects on mineralocorticoids)
why do you get hyperpigmentation in primary adrenal insufficiency
ACTH is increased because you have low cortisol

a breakdown product is MSH

this hits the melanocyte receptors
symptoms of chronic adrenal insufficiency
Fatigue

Weight Loss

Weakness
dehydration, hypotension, shock. Nausea, vomiting with weight loss and anorexia. Abdominal pain, so called "acute abdomen". Unexplained hypoglycemia and fever. Hyponaterima, hyperkalemia, azotemia, hyperpigmentation... all findings suggestive of...
adrenal crisis
what is a good steroid to start with as tx for adrenal insufficiency
Dexamethasone
tx for primary adrenal insufficiency?
Glucocorticoids: Predinozone, Hydrocortizone, Dexamethazone

Mineralocorticoids: Fludrocortizone
tx for secondary adrenal insufficiency?
just the Glucocorticoids
26 year old lady comes with increased facial fullness and increased facial hair. Episode of depression and acute psychosis following the delivery. Her menses have been irregular since they resumed after the birth, she is not breast feeding. Proximal muscle weakness, easy bruising. She is on SSRI and prenatal vitamins. She is obese with striae present since pregnancy. She has a full face with mild acne and a dorsocervical fat pad. What test should you order? what do you think they have?
24 hour urine for free cortisol or Dexamethazone suppression test

Cushing
What is Cushing's DISEASE
ACTH secreting tumor in ant pituitary
what is the most common cause of cushings SYNDROME
Exogenous steroids
alcoholism can cause what type of cortisol problem?
PSEUDOCUSHINGS
Tx for Cushing's syndrome?
depends on cause

surgery, medicine, etc
spinal levels for adrenal glands?
T8-T10
lady has lump in the neck for about 3 years. She was unaware of other nodules, denies weight loss/gain, fatigue, dysphagia. Mother was dx with multinodular goiter when she was 40
papillary carcinoma
are thyroid nodules common?
you bet your booty
most common thyroid cancer? prognosis?
paipillary carcinoma

prognosis is good even though you often see mets!
besides papillary carcinoma of the thyroid, what other cancers are there? Which is worst?
follicular, medullary, anaplastic (WORST)
if someone is undergoing a thyroidectomy what do you have to do post surgery?

***TEST
monitor Ca! you might have taken out the parathyroid

pt may complain of weakness
who is more likely to die of thyroid cancer?
MEN
after thyroidectomy pt says they are gaining weight, dry skin, menstrual cycles were unusually heavy and prolonged..what is going on? how would you tell?
hypothyroid

get TSH and T4
what can cause primary hypothyroid
Hashimoto's--autoimmune, most common in US

Iodine deficiency--most common world wide

drugs, surgery, etc
elevated TSH shows what?
HYPOTHYROID
when do you recheck TSH levels?
6-8 weeks
life threatening complication of hypothyroidism?
Myexedma coma
who do you see Myexedema coma in? What causes it?
old folk

not taking their meds correct
which of the following shows hypothyroid

normal t4 low TSH
normal T4 high tsh
Low T4 high TSH
normal T4 normal TSH
Low t4 borderline low TSH
Low T4 high TSH
pt is jittery, nervous, weight loss, heat intolerance...
Hyperthyroid
what is thyroid storm? causes?
extreme hyperthyroidism...life threatening

caused by stress: surgery, infection, radioiodine tx

mortality is about 30%
how do you treat thyroid storm?
get underlying cause

B-blockers can help symptoms

iodine salts
OPP tx areas for thyroid
T1-5 (head and neck)

also consider sternum (could be twisted)
**OPP**

Sympathetics for Kidneys and Adrenals?
Kidneys: T10-11

Adrenals: T8-10 ipsilateral
**OPP**

Chappman's points for kidneys?
Anterior: 1" superior, 1" lateral to umbilicus

Posterior: L1 transverse process
**OPP**

Chappman's points for adrenals?
Anterior: 2" superior, 1" lateral to umbilicus

Posterior: T11 transverse process