Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
88 Cards in this Set
- Front
- Back
|
What happens in adrenal insufficiency?
|
Adrenal glands are pooped: inappropriately low adrenal steroid output:
Mineralocorticoids Glucocorticoids Sex steroids |
|
|
What happens in cushing's?
|
Too much cortisol
|
|
|
What happens in primary hyperaldosteronism?
|
Too much aldosterone
|
|
|
What is the main flavor of adrenal insufficiency?
|
Cortisol deficiency
|
|
|
What does the HPA axis look like in primary adrenal insufficiency?
|
|
|
|
What does the HPA axis look like in secondary adrenal insufficiency?
|
|
|
|
What does the HPA axis look like in tertiary adrenal insufficiency?
|
|
|
|
What's the key molecule for differentiating between primary and secondary adrenal insufficiency?
|
Primary: aldo will be low
Secondary: aldo won't be abnormal |
|
|
What is the main cause of adrenal insufficiency? Second most common?
|
Autoimmune adrenalitis
Pharmacologic dose of glucocorticoids |
|
|
What's the most common cause of adrenal insufficiency in the elderly?
|
Pharmacologic doses of glucocorticoids
|
|
|
What are some of the causes of primary adrenal insufficiency?
|
Autoimmune adrenalitis (80%)
Adrenal Tb (20%) Adrenal hemorrhage |
|
|
What can autoimmune adrenalitis happen in the context of, often?
|
Polyglandular autoimmune syndromes:
-Polyglandular AI syndrome I |
|
|
What are the diagnostic criteria for polyglandular autoimmune syndrome I?
|
2 of the following:
-Adrenal insufficiency (<15 YO) -Hypoparathyroidism (<10 YO) -Chronic mucocutaneous candidiasis (<5 YO) |
|
|
What are the symptoms of primary adrenal insufficiency?
|
Cortisol related:
Fatigue Weakness and malaise Anorexia Nausea, vomiting Aldosterone related: Dizziness |
|
|
What are signs of primary adrenal insufficiency?
|
Proximal muscle weakness
Orthostatic hypotension Hyperpigmentation (PRIMARY AI ONLY.) HypoNa, HyperK (PRIMARY AI ONLY.) |
|
|
Where do you look for hyperpigmentation in primary adrenal insufficiency?
|
Palmar creases
|
|
|
Does primary aldosterone deficiency happen in isolation?
|
NO.
|
|
|
What are the electrolyte abnormalities in aldosterone deficiency?
|
|
|
|
What is the cause of hyponatremai in primary adrenal insufficiency?
|
1. Lack of aldosterone-->can't reabsorb Na-->volume depletion
2. ADH secretion to reabsorb water to perrfuse essential organs 3. Decreased serum osmolality, Na concentration -->hyponatremia |
|
|
What are the symptoms of cortisol deficiency?
|
Hypotension
Hypoglycemia Fatigue |
|
|
What are the symptoms of DHEAs deficiency?
|
Fatigue
Depressed mood Libidinal dysfunction |
|
|
What is the source of DHEAS?
|
Adrenal gland.
|
|
|
What is the main source of androgens in males? Females?
|
Males: testicles
Females: adrenals |
|
|
What is DHEA a precursor to?
|
Testosterone
|
|
|
If a woman doesn't have an adrenal gland and doesn't have a libido either, what can you give her?
|
DHEAS
|
|
|
What occurs in an adrenal crisis?
|
Acute CV collapse due to adrenal insuficiency
|
|
|
What are the causes of an adrenal crisis?
|
Hemorrhage
Infection Withdrawal of exogenous glucoccorticoids |
|
|
What is Waterhouse-Friderichsen syndrome?
|
Traditionally, Neiserria induced destruction of the adrenal gland
|
|
|
What are drugs that increase the metabolism of GCs?
|
Phenytoin
Phenobarbitol Rifampin |
|
|
What are the drugs that decrease the synthesis of GCs?
|
Ketoconazole
Mitotane Metyrapone |
|
|
What are causes of secondary and tertiary insufficiency?
|
Vascular
Lymphocytic hypophysitis Infiltritative diseases: sarcoid, histocytosis Tumor compression Surgery |
|
|
What are the symptoms of secondary adrenal insufficiency?
|
Mild malaise, fatigue
Proximal weakness |
|
|
What are the signs of secondary adrenal insufficiency?
|
Milder than primary
NO hyperpigmentation NO orthostatic hypotension |
|
|
What IS NOT deficient in secondary adrenal insufficiency?
|
Aldosterone
|
|
|
When should you have a high index of suspicion for an adrenal crisis?
|
Catecholamine resistant hypotension
Hypotension with abdominal pain Hyperpigmentation Decreased pubic hair Hyperkalemia Hyponatremia hypoglycemia |
|
|
What's the testing for adrenal insuficciency?
|
AM cortisol: rule out disease
-If high, DISEASE IS RULED OUT. -If exceptionally low, it's diagnostic |
|
|
What's the gold standard for adrenal insufficiency?
|
ACTH stimulation test
|
|
|
What's the interpretation of the ACTH stimulation test?
|
Subnormal cortisol levels: diagnostic of AI
ACTH extremely high: consistent with diagnosis, but not diagnostic. |
|
|
What's the diagnostic test for secondary adrenal insufficiency?
|
Insulin hypoglycemia test.
|
|
|
What's the underlying pathophysiology beneath secondary adrenal insufficiency?
|
The gland atrophies. When you then challenge it, it cannot respond.
|
|
|
What happens in an insulin hypoglycemia test?
|
You initiate hypoglycemia via insulin.
If you have subnormal cortisol--->diagnosis of AI If you have ACTH that is subnormal--> diagnosis of secondary AI |
|
|
What's the management for adrenal crisis?
|
IV fluids
IV cortisol Glucose Treat underlying cause! DON'T WAIT FOR LABS. |
|
|
What is the maintenance therapy for adrenal insufficeincy?
|
Hydrocortisone
Fludrocortisone |
|
|
What is off in Cushing's syndrome?
|
Cortisol.
|
|
|
What is a cause of catecholamine excess?
|
Pheochromocytoma
|
|
|
What are the symptoms of a pheochromocytoma?
|
Headache
Sweating Palpitation panic HTN |
|
|
What occurs in 21 alpha hydroxylase deficiency?
|
Lack of aldosterone
Lack of cortisol |
|
|
What happens when there's an isolated step blocked in steroid production?
|
Shunting down an alternate path
Build up of precursors before the block |
|
|
What happens in severe forms of adrenal insensitivity syndrome? Milder forms?
|
Severe: virulization of females
Milder: hirsuitism + menstrual abnormalities |
|
|
What is the function of testosterone in a male fetus?
|
Development of sexual characteristics
|
|
|
What's the most common gonadal steroid defect?
|
Androgen insensitivity syndrome
|
|
|
What underlies androgen insensitivity syndrome?
|
Loss of function at the androgen receptor
|
|
|
What is the pathophys of androgen insensitivity syndrome?
|
Block in androgen activiyt leads to increased testosterone
High levels of testosterone get converted to estrogens peripherally |
|
|
What are the different types of Cushing's?
|
Adrenal: autonomous production of Cortisol; low ACTH
ACTH dependent; high ACTH |
|
|
What are some causes of adrenal steroid excess?
|
Adrenal tumor (cortisol producing) - left
Pituitary tumor (ACTH producing) -right Other tumors (ectopic ACTH/CRH) |
|
|
What are the hormone changes in adrenal steroid excess?
|
|
|
|
What is Cushing's disease?
|
ACTH producing tumor in the PITUITARY!
It's a nomenclature thing. |
|
|
What are the different kinds of cushing's syndroem?
|
|
|
|
How common are the different flavors of Cushing's?
|
85% pituitary
15ish% adrenal 1% ectopicc |
|
|
If Cushing's is ACTH dependent, what kind is it likely to be?
|
Pituitary adenoma
|
|
|
What occurs to the adrenals in ACTH dependent Cushing's?
|
Bilateral hyperplasia
|
|
|
What kinds of tumors can cause ACTH dependent Cushing's?
|
Bronchial carcinoid
Oat cell carcinoma THymic carcinoid Pheochromocytoma Medullary thyroid cancer |
|
|
What are underlying causes of ACTH-indpendent cushing's?
|
Adrenal carcinoma
Adrenal adenoma |
|
|
What happens to the adrenal glands in an ACTH independent Cushing's?
|
One is big (the one with the tumor, that is.)
The contralateral gland is SMALL! |
|
|
If you take a primary adrenal tumor out that has been causing ACTH independent Cushing's out, what do you need to give the patient?
|
Steroid replacement: you don't want to just shove them into adrenal insufficiency
|
|
|
What are the responses of the body to cortisol overproduction?
|
Glucose production
Muscle breakdown Fat production |
|
|
What are the manifestations of cortisol excess?
|
HTN
DM Obesity Muscle wasting |
|
|
What are the clinical manifestations of cortisol excess?
|
Increased protein catabolism
DM Truncal obesity Osteoperosis HTN Opportunistic infections Amenorrhea, impotence |
|
|
What finding will you see only with an ACTH dependent cushing's?
|
Pigmentation due to MSH
|
|
|
How do we go about diagnosing Cushin's?
|
1. Diagnose cortisol excess
2. Diagrnose the pathologic cortisol excess 3. See if it's ACTH dependent or not. |
|
|
How do you check for a pathologic cortisol excess?
|
See if the axis is suppressed with low-dose dexamethasone
|
|
|
IN what patients will low dose dexamethasone have no effect?
|
ACTH dependent cushing's due to a pitituitary adenoma or ectopic ACTH
ACTH independent cushings due to adrenal tumors |
|
|
In what patients will low-dose dexamethasone have an effect?
|
Normal patients
Physiologic hypercortisolism |
|
|
How do you differentiate between a pituitary or exctopic cause of cushing'?
|
High dose DEX
Ectopic tumors NEVER suppress to high dose DEX Pituitary MAY suppress Inferior petrosal sinus sampling: -Measure ACTH levels in different placeces (near pituitary, in the periphery) |
|
|
What are the most common types of ectopic tumors?
|
Lung (SCC, bronchial)
|
|
|
What's the treatment for Cushing's?
|
Adrenal adenoma: resect, replace cortisol
Pituitary adenoma: transphenoidal resection, cortisol replacement Ectopic: FIND THE TUMOR. |
|
|
How does a female present with adrenal steroid excess?
|
Hirsuitism
Cliteromegaly Amenorrhea Acne |
|
|
How does a male present with adrenal sex steroid excess?
|
Gynecomastia
Erectinal dysfunction Libidinal dysfunction |
|
|
What are the symptoms of aldosterone excess?
|
HTN
Low potassium |
|
|
What are the symptoms of low potassium?
|
NM problems: paresthesias, weakness, tetany
|
|
|
What are the the other symptoms of hypoaldosteronism?
|
NM problems due to K
Renal: polyuria Carbs: abnormal glucose tolerance test HTN |
|
|
What is the quality of the HTN during hypoaldosteronism?
|
It's not malignant
|
|
|
What are causes of hyperaldosteronism?
|
Renal tumor making aldosterone (MOST COMMON)
Hyperplasia of the glomerulosa JGA tumor making renin Receptor problems. RENAL ARTERY STENOSIS! |
|
|
What do you need to find out about hyperaldosteronism?
|
Is the aldo indpendent or not.
|
|
|
How do you check to see if a tumor is renin caused or not?
|
Give the person volume.
-If both go down, then they're just volume depleted -If just renin goes down, it's hyperaldosteronism -If neither goes down, it's either renal artery stenosis or a renin-producing tumor |
|
|
What are the most common causes of hyperaldosteronism?
|
ZG aldo tumor - 70%
ZG aldo hyperplasia - 30% |
|
|
What's the workup for hyperaldosteronism?
|
1. Work up other causes of low K
24 hr. urine aldosterone -If high, then they're hyperaldosterone Then, check renin -If high, JGA renin tumor or RAS -If low, primary hyperaldosteronism |
|
|
What do you do after you confirm hyperaldosteronism?
|
CT scan: look for tumor.
Look to see if there's high aldo on 1 side via a catheter. |
