Abdominal pain Flashcards
What is the definition of orthostatic hypotension in a patient without a pre-existing diagnosis of HTN?
A fall in systolic blood pressure of at least 20 mmHg and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing
What are the layers of the adrenal cortex and which hormones do they produce?
zona glomerulosa - aldosterone
zona fasciculata - cortisol
zona reticularis - dehydroepiandrosterone
medulla - catecholamines
What causes primary hypoadrenalism?
Addison’s (autoimmune)
infection (TB, pseudomonas, meningococcal)
metastatic malignancy
adrenal haemorrhagic infarction (warfarin, heparin, anti-phospholipid syndrome)
drugs (ketoconazole, etomidate, metyrapone, mitotane)
What is the best way to confirm hypoadrenalism?
short synacthen test
How would you carry out a short synacthen test?
- ensure glucocorticoid has not been given
- Blood is taken early in the morning for cortisol and ACTH levels and sent to the lab immediately on ice
- 250micrograms of synthetic ACTH is given
- Blood is taken at 30 minutes for cortisol
- A 30 min cortisol of >450nmol/L indicates normal adrenal function and no further investigations are required. A cortisol level of <450nmol/l indicates hypoadrenalism and warrants further investigation
What is the
most important drug in the initial treatment of Addison’s?
hydrocortisone - 200mg iv every 24 hours, either as a continuous IV infusion or 50mg IV every 8 hours until stable (glucocorticoid replacement)
Once a patient with Addison’s has stabilised, which medications should they be on?
oral hydrocortisone 15-20mg at 8am and 5-10mg at 5pm
0.1-0.2mg oral fludrocortisone
What factors contribute to constipation in hospital?
underlying medical conditions pain medication dehydration change in diet reduced mobility
In an abdominal system what would you be looking for in an end of the bed inspection?
scratch marks
gynaecomastia
tremor
pigmented patches
In an abdominal system what would you be looking for in the eyes?
jaundice, conjunctiva, xanthelasma, Kayser-Fleischer rings, central cyanosis, angular stomatitis, pigmentation
In an abdominal system what would you be looking for in the hands?
clubbing, koilonychia, leuconychia, Dupytren’s contracture, palmar erythema
What are the six causes of abdominal distension?
fat faeces flatus foetus fluid flipping big tumour
What controls the pituitary gland?
hormone secretion from the hypothalamus
What is the function of the pituitary gland?
anterior: GH, prolactin, LH, FSH, ACTH, TSH
posterior: oxytocin, ADH
What are the causes of hypopituitarism?
hypothalamus: Kallmann’s syndrome, tumour inflammation, TB, meningitis, ischaemia
pituitary stalk: trauma, surgery, mass lesion, meningioma, carotid artery aneurysm
pituitary gland: tumour, irradiation, inflammation, amyloid, haemochromatosis, metastatic Ca, ischaemia
What are the clinical features of reduced GH production?
central obesity atherosclerosis dry, wrinkly skin reduced strength and balance reduced exercise tolerance hypoglycaemia osteoporosis
What are the clinical features of reduced gonadotrophin production?
males: ED, reduced libido, reduced muscle bulk, small testes
females: oligo/amenorrhoea, reduced fertility, reduced libido, breast atrophy, osteoporosis
What are the clinical features of reduced thyroid hormone production?
tired/sleep/lethargy, low mood, feeling cold all the time, increase in weight, slow bowels, hair loss, heavy periods, cramps, weakness
What are the clinical signs of reduced thyroid hormone production?
bradycardia. reflexes relax slowly, ataxia, dry skin, yawning, cold hands, ascites, round face, defeated demeanor, immobile, CCF
What are the clinical features of reduced corticotrophin production?
dizziness, flu-like myalgia, nausea, vomiting, abdo pain, no increased skin pigmentation
What clinical featues may be seen in a pituitary gland tumour?
- mass effect: compression of optic chiasm
- secretion of hormones with resultant reduction in other hormones: hyperthyroidism, acromegaly, Cushings, hyperprolactinaemia
What are the clinical features of agromegaly?
prominent forehead, arthritis, large nose, large hands, large feet, macroglossia, prognathism
How would you treat hypopituitarism?
- treat underlying cause: surgery or tumour suppression
- replace lacking hormone: hydrocortisone, thyroxine, oestrogen/testosterone, gonadotropin therapy
