Abdominal pain

Question 1

What is the definition of orthostatic hypotension in a patient without a pre-existing diagnosis of HTN?

Answer 1

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

Question 2

What are the layers of the adrenal cortex and which hormones do they produce?

Answer 2

zona glomerulosa - aldosterone
zona fasciculata - cortisol
zona reticularis - dehydroepiandrosterone
medulla - catecholamines

Question 3

What causes primary hypoadrenalism?

Answer 3

Addison’s (autoimmune)
infection (TB, pseudomonas, meningococcal)
metastatic malignancy
adrenal haemorrhagic infarction (warfarin, heparin, anti-phospholipid syndrome)
drugs (ketoconazole, etomidate, metyrapone, mitotane)

Question 4

What is the best way to confirm hypoadrenalism?

Answer 4

short synacthen test

Question 5

How would you carry out a short synacthen test?

Answer 5

• 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

Question 6

What is the

most important drug in the initial treatment of Addison’s?

Answer 6

hydrocortisone - 200mg iv every 24 hours, either as a continuous IV infusion or 50mg IV every 8 hours until stable (glucocorticoid replacement)

Question 7

Once a patient with Addison’s has stabilised, which medications should they be on?

Answer 7

oral hydrocortisone 15-20mg at 8am and 5-10mg at 5pm

0.1-0.2mg oral fludrocortisone

Question 8

What factors contribute to constipation in hospital?

Answer 8

underlying medical conditions
pain
medication
dehydration
change in diet
reduced mobility

Question 9

In an abdominal system what would you be looking for in an end of the bed inspection?

Answer 9

scratch marks
gynaecomastia
tremor
pigmented patches

Question 10

In an abdominal system what would you be looking for in the eyes?

Answer 10

jaundice, conjunctiva, xanthelasma, Kayser-Fleischer rings, central cyanosis, angular stomatitis, pigmentation

Question 11

In an abdominal system what would you be looking for in the hands?

Answer 11

clubbing, koilonychia, leuconychia, Dupytren’s contracture, palmar erythema

Question 12

What are the six causes of abdominal distension?

Answer 12

fat
faeces
flatus
foetus
fluid
flipping big tumour

Question 13

What controls the pituitary gland?

Answer 13

hormone secretion from the hypothalamus

Question 14

What is the function of the pituitary gland?

Answer 14

anterior: GH, prolactin, LH, FSH, ACTH, TSH
posterior: oxytocin, ADH

Question 15

What are the causes of hypopituitarism?

Answer 15

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

Question 16

What are the clinical features of reduced GH production?

Answer 16

central obesity
atherosclerosis
dry, wrinkly skin
reduced strength and balance
reduced exercise tolerance
hypoglycaemia
osteoporosis

Question 17

What are the clinical features of reduced gonadotrophin production?

Answer 17

males: ED, reduced libido, reduced muscle bulk, small testes
females: oligo/amenorrhoea, reduced fertility, reduced libido, breast atrophy, osteoporosis

Question 18

What are the clinical features of reduced thyroid hormone production?

Answer 18

tired/sleep/lethargy, low mood, feeling cold all the time, increase in weight, slow bowels, hair loss, heavy periods, cramps, weakness

Question 19

What are the clinical signs of reduced thyroid hormone production?

Answer 19

bradycardia. reflexes relax slowly, ataxia, dry skin, yawning, cold hands, ascites, round face, defeated demeanor, immobile, CCF

Question 20

What are the clinical features of reduced corticotrophin production?

Answer 20

dizziness, flu-like myalgia, nausea, vomiting, abdo pain, no increased skin pigmentation

Question 21

What clinical featues may be seen in a pituitary gland tumour?

Answer 21

• mass effect: compression of optic chiasm
• secretion of hormones with resultant reduction in other hormones: hyperthyroidism, acromegaly, Cushings, hyperprolactinaemia

Question 22

What are the clinical features of agromegaly?

Answer 22

prominent forehead, arthritis, large nose, large hands, large feet, macroglossia, prognathism

Question 23

How would you treat hypopituitarism?

Answer 23

• treat underlying cause: surgery or tumour suppression

- replace lacking hormone: hydrocortisone, thyroxine, oestrogen/testosterone, gonadotropin therapy