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Endo, Cardio and Neuro > Adrenal Disorders > Flashcards

Adrenal Disorders Flashcards

1
Q

where are corticosteroids synthesised?

A

adrenal cortex

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2
Q

examples of corticosteroids

A 
mineralcorticoids (aldosterone)
glucocorticoids (cortisol)
sex steroids (androgens, oestrogen)
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3
Q

what is the precursor of a steroid?

A

cholesterol

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4
Q

what is the effect of angiotensin II on the adrenals?

A

activates:
3-hydroxysteroid dehydrogenase
11, 21, 18-hydroxylase

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5
Q

what is the effect of ACTH on the adrenals?

A

activates: 3-hydroxysteroid dehydrogenase

11, 21 and 17-hydroxylase

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6
Q

what is addisons disease?

A

primary adrenal failure

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7
Q

what is the most common cause of Addisons worldwide?

A

tuberculosis of the adrenal glands

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8
Q

what is the most common cause of Addisons in the UK?

A

autoimmune destruction of the adrenal glands

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9
Q

what are the main signs of Addisons disease?

A

skin and mucous membrane pigmentation
weight loss
vomiting, diarrhoea
low blood pressure

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10
Q

what are the physiological consequences of addisons?

A 
low BP
loss of salt in urine
increased plasma potassium 
low blood glucose
increased skin pigmentation
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11
Q

why does high ACTH lead to increased pigmentation?

A

POM-C is cleaved to form ACTH and MSH (and endorphins) so pathologically high ACTH may lead to tanned skin

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12
Q

what tests should be performed if Addisons is suspected?

A

9am cortisol

short synACTHen test

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13
Q

what is a short synACTHen test?

A

give 250ug synACTHen IM

measure cortisol response (should increase)

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14
Q

how is Addisons treated?

A

fludrocortisone 50-100mg

and either hydrocortisone 3x daily(10, 5, 2.5mg) OR prednisolone 3mg daily

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15
Q

what is the most common congenital adrenal hyperplasia?

A

21-hydroxylase deficiency

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16
Q

what is complete 21-hydroxylase deficiency?

A

missing 21-hydroxylase from birth

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17
Q

what hormones are absent in complete 21-hydroxylase deficiency?

A

aldosterone and cortisol

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18
Q

which hormones are in EXCESS in complete 21-hydroxylase deficiency?

A

sex steroids and testosterone

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19
Q

what are the signs of someone with complete 21-hydroxylase deficiency?

A

neonate with salt-losing addisonian crisis

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20
Q

what do girls with complete 21-hydroxylase deficiency develop?

A

ambiguous genitalia, virilised by adrenal testosterone (males usually okay)

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21
Q

how do partial and complete 21-hydroxylase deficiency present differently?

A

partial may present much later in life as is not fatal without treatment. males may present with precocious puberty and females with hirsutism and virilisation

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22
Q

what is virilisation?

A

development of male physical characteristics in females/precocious boys

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23
Q

what hormones are deficient in 11-hydroxylase deficiency?

A

cortisol and aldosterone

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24
Q

what hormones are in excess in 11-hydroxylase deficiency?

A

sex steroids - testosterone

11-deoxycortisterone

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25
Q

what do individuals with 11-hydroxylase deficiency present with?

A

virilisation,
HYPERtension
HYPOkalaemia

26
Q

what does 11-deoxycorticosterone act like?

A

aldosterone - excess can cause hypertension and hypokalaemia

27
Q

what hormones are deficient in 17-hydroxylase deficiency?

A

cortisol and sex steroids

28
Q

what hormones are in excess in 17-hydroxylase deficiency?

A

11-deoxycorticosterone and aldosterone (mineralocorticoids)

29
Q

what do individuals with 17-hydroxylase deficiency present with?

A 
hypertension, 
hypokalaemia, 
infertility, 
low libido, 
erectile dysfunction 
low glucose
30
Q

what is cushings syndrome?

A

high cortisol

31
Q

what are the main signs of cushings disease?

A 
centripedal obesity, moon face, buffalo hump
proximal myopathy
hypertension and hypokalaemia
red striae, thin skin, bruising
osteoporosis, diabetes
32
Q

what is the main cause of cushings syndrome?

A

taking steroids
pituitary adenoma
ectopic ACTH lung cancer
adrenal adenoma

33
Q

what is cushings disease?

A

cushings syndrome caused by pituitary adenoma

34
Q

how is cushings syndrome diagnosed?

A

24hr urine collection for urinary free cortisol
blood diurnal cortisol levels
low dose dexamethasone suppression test

35
Q

what is a low dose dexamethasone test?

A

0.5mg 6 hourly doses of artificial steroid for 48hrs

any cause of cushings will fail to suppress cortisol (normal should go to 0)

36
Q

how do you treat cushings?

A

metyrapone or ketoconazol medication
pituitary surgery
bilateral or unilateral adrenalectomy

37
Q

what is metyrapone used for?

A

control of cushings prior to surgery (promotes better wound healing)
control of cushings after radiotherapy (while waiting for it to work)

38
Q

what are the side effects of metyrapone?

A

hirsutism

hypertension if long term

39
Q

what is ketoconazole used for?

A

mainly an antifungal,

at high doses - control and treatment of cushings syndrome

40
Q

what is ketoconazoles mechanism of action?

A

inhibits steroidogenesis by 17a-hydroxylase

41
Q

when is a bilateral adrenalectomy typically performed?

A

for ectopic ACTH lung cancer

42
Q

when is a unilateral adrenalectomy typically performed?

A

for adrenal masses

43
Q

what is Conns syndrome?

A

benign adrenal cortical tumour of zona glomerulosa
with hyperaldosteronaemia
aka primary hyperaldosteronism

44
Q

how does Conns syndrome present?

A 
hypertension
muscle cramps
heart palpitations
hypokalaemia
anxiety
headaches
45
Q

how is conns syndrome diagnosed?

A 
measuring renin (low) and aldosterone levels (high)
low potassium (hypokalaemia)
46
Q

what is spironolactone used for?

A

primary hyperaldosteronism (conns syndrome)

47
Q

how does metyrapone work

A

blocks 11-hydroxylase
therefore no production of cortisol or corticosterone
side effects casued by buildup of 11-deoxycorticosterone in zona glomerulosa - hypertension

48
Q

treatment of conns syndrome

A

spironolactone (or epleronone)

and removal of tumour

49
Q

spironolactone side effects

A

gynaecomastia

menstrual abnormalities

50
Q

what is a phaeochromocytoma?

A 
tumour of adrenal medulla
neuroendocrine cells
secretes catecholamines (nor/adrenaline)
51
Q

how is phaeochromocytoma different to other adrenal tumours?

A

neuroendocrine cells
it stores the adrenaline then suddenly releases it unlike a steady release of hormones
therefore symptoms can come on very suddenly - blood pressure rises etc

52
Q

signs of phaeochromocytoma

A

intermittent severe hypertension - especially after abdominal palpation
hypertension in young

53
Q

risks due to phaeochromocytomas

A 
myocardial infarction
stroke
ventricular fibrillation
sudden death
medical emergency!
54
Q

management of phaeochromacytoma

A

alpha adrenoreceptor blocker and give fluids to prevent a bp crash
beta blocker to prevent tachycardia
then removal of tumour surgically

55
Q

types of phaeochromocytoma

A

extra-adrenal (somewhere in sympathetic chain)
bilateral
malignant
heritable

56
Q

what is a salt losing addisonian crisis

A

body unable to retain salt (sodium) as its lost in urine

crash in blood pressure

57
Q

what should you suspect if a baby is born with ambiguous genitalia

A

21 hydroxylase deficiency - give NaCl fluids just in case of crisis

58
Q

practice drawing the adrenal steroid pathway on paper RN

A

you better have done it

59
Q

treatment of 21-hydroxylase deficiency

A

replacement for aldosterone and cortisol so

single morning dose of prednisolone 3mg

60
Q

symptoms of phaechromocytoma

A 
severe intermittent hypertension
heavy sweating
palpitations and tachycardia
shortness of breath 
panic-attack like symptoms
61
Q

easy ways to remember CAHs

A

If the enzyme deficiency starts with 1 (eg. 11 or 17 hydroxylase) → it causes hypertension.

If the enzyme deficiency ends with 1 (eg. 11 or 21 hydroxylase) → it causes virilisation in females and precocious puberty in males

  • In each of these conditions, the absence of an enzyme results in decreased cortisol, which causes:
    • Hyperpigmentation (due to decreased negative feedback → elevated ACTH → increased MSH from POMC breakdown)
    • Hypoglycaemia (because one of the functions of cortisol is to promote gluconeogenesis)
    • Nausea and vomiting (mechanism unclear but this is a classic symptom of adrenal insufficiency)

Endo, Cardio and Neuro (22 decks)

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