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DEMS Unit 3 > Adrenal disorders > Flashcards

Adrenal disorders Flashcards

1
Q

Name what they produce:
Zona Glomerulosa
Zona Fasiculata
Zona Reticularis

A

Zona Glomerulosa
- Aldosterone

Zona Fasiculata
- Cortisol

Zona Reticularis
- Androgens

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2
Q

Using the Hypothlamaic pituitary adrenal axis, describe the production of cortisol, aldosterone, and adrenal androgens

A
  1. Hypothalamus makes CRH + AVP
  2. ACTH is made from the pituitary gland
  3. Signals the adrenal glands to make cortisol, aldo, androgens
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3
Q

RAAS

A
  1. Adrenal gland makes aldosterone
  2. Signals the kidney to make Renin
  3. Renin converts Angiotensinogen (which is made in liver) to Angiotensin I
  4. ACE (in lungs) converts Angiotensin I to Angiotensin II
  5. AG II causes vasoconstriction (increase BP)
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4
Q

Causes of Primary Adrenal insufficiency

  1. Autoimmune:
  2. Infectious:
  3. Infiltrative
  4. Other
A
  1. Autoimmune:
    - Addison’s dz
  2. Infectious:
    - TB, Fungi, HIV
  3. Infiltrative:
    - Amyloid
  4. Other
    - Hemorrhage
    - Metastatic
    - Metabolic
    - Surgery

*All will result in lower amts of cortisol, aldo, androgens

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5
Q

Symptoms of Adrenal insufficiency

A

Non specific
- Fatigue, weakness, myalgias, arthralgias, anorexia, n/v, HA, abdominal pain, weight loss, postural dizziness, salt cravings

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6
Q

Signs of Adrenal insufficiency

SIgns of primary adrenal insufficiency

A

ALL:
- Hypotension, Tachycardia

Primary:
- Vitiligo, pigmentation

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7
Q

Labs of Adrenal insufficiency

A
  1. HYPERkalemia (primary only)
  2. HYPOnatremia
  3. HYPOglycemia
  4. Azotemia (high BUN + sr Creatinine)
  5. Anemia
  6. Eosinophilia
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8
Q

How to dx Primary adrenal insufficiency

A
  1. Serum cortisol
    100 pg/ml
  2. Adrenal CT Scan
    Small: autoimmune, metabolic
    Large: all other causes
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9
Q

Hashimoto’s thyroiditits (causing hypothyroidism) is it APS 1 or APS 2?

A

APS-2

HLA associated

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10
Q

Best imaging for adrenal insufficiency

A

CT

Small: autoimmune, metabolic
Large: all other causes

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11
Q

Secondary adrenal insufficiency is due to what?

A
  1. Glucocorticoids
  2. Opioids
  3. Tumor
  4. Surgery
  5. Radiation
  6. Infectious
  7. Hemorrhage
  8. Infiltrative
  9. Metastatic

*Low CRF, Low ACTH –>
Low cortisol, NL aldosterone (no hyperkalemia), low adrenal androgens

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12
Q

How to dx secondary adrenal insufficiency

A

Almost same as primary:

1. Serum cortisol

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13
Q

Tx for adrenal insufficiency

A

Glucocorticoid replacement

  • Hydrocortisone
  • Prednisone
  • Dexamethasone

Mineralocorticoid Replacement
- Fludrocortisone

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14
Q

Triad of Primary aldosteronism

A
  1. HTN
  2. Hypokalemia
  3. Metabolic alkalosis
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15
Q

Two types of primary aldosteronism

A
  1. Aldosterone producing adenoma (APA)
    34%
  2. Idiopathic Hyperaldosteronism (IHA)
    66%
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16
Q

Who to screen for primary aldosteronism?

A

Hypertensive patients with:

  1. Hypokalemia
  2. Severe HTN (>160/100)
  3. Resistant HTN
  4. HTN onset
17
Q

Positive screen for primary aldosteronism

Confirming test

A 
Positive screen:
1. Morning plasma aldosterone (PA)
>15 ng/dl AND
2. PA/Plasma renin activity (PRA) ratio
>20

Confirmation test:

  1. Oral salt load > 12 ug on urine aldosterone on 3rd day
  2. IV saline infusion(2L NS over 4 hrs)
18
Q

Medication restriction for primary aldosteronism

A

Spirinolactone

- aldosterone antagonist

19
Q

What is a surgical disease? What is medical management only?

APA vs IHA?

A

APA: surgical management is option

  • start with abdominal CT scan
  • If cant visualize, do adrenal vein sampling

IHA: medical management only

20
Q

Direct aldosterone antagonist on kidney

A

Spirinolactone

Eplerenone

21
Q

Tx for primary aldosteronism (APA)

A 
preop:
Aldosterone antagonist (spirin, epleren)

Adrenalectomy:
Laparoscopic/open

22
Q

Tx for primary aldosteronism (IHA)

A 
preop:
Aldosterone antagonist (spirin, epleren)

BP medication:
CCB
ACE I
ARB

23
Q

Pheochromocytoma triad (4)..

A

HTN +
HA +
Sweating +
Palpitation

Due to excess catecholamine production

24
Q

Rule of 10s for pheochromocytoma

A

10% are malignant
10% are familial
10%are bilateral
10% are extra adrenal

25
Q

Familial syndromes that can lead to pheochromocytoma

A
  1. MEN type 2A/2B
  2. Von Hippel Lindau Syndrome
  3. Neurofibromattosis Type I
  4. Familial paragangliomas (Succinyl dehydrogenase SDH mutation)
26
Q

Who to screen for pheochromocytoma

A

Hypertensive patients with:

  1. SPells
    - HA, sweating, palpitations
  2. Severe HTN (>160/100)
  3. Resistant HTN (>2 drugs)
  4. Adrenal incidentaloma
  5. Familial syndrome
27
Q

Best screening test for pheochromocytoma

A

Urine metanephrines and catecholamines
sensitivity 90%
specificity 98%

28
Q

What can cause false positives for pheochromocytoma (cause elevated catecholamines)

A
  1. Levodopa
  2. Ethanol
  3. TCA
  4. Buspirone (antipsychs)
  5. Acetaminophen
  6. Amphetamines, Opioids
  7. Clonidine withdrawl
  8. Renal failure
  9. Sleep apnea
  10. Physical stress
29
Q

Preop management for pheochromocytoma prior to adrenalectomy

A

Hypertensive, but hypovolemic (cant suddenly vasodilate them)

  1. Alpha blockers (1st)
    - block norepi (Phenoxybenzamine, prazosin, terazosin, Doxazosin)
  2. Beta blockers (2nd after alpha blockade)
  3. CCB (alone)

Tx effects:
- volume expansion, vasodilation, rate control

30
Q

Cushing syndrome is due to what?

A

Exogenous steroids - most common cause

The rest are adenoma-like:

80% are due to ACTH secreting pituitary tumor (cushing disease)

  • increase cortisol, NL aldosterone, increase adrenal androgens
  • ACTH dependent cushing syndrome

10% is due to cortisol secreting adrenal tumor (not ACTH secreting)
- ACTH independent cushing syndrome

31
Q

Symptomes of cushing syndrome

Signs

A

Santa Claus:

  1. facial plethora
  2. easy bruising
  3. Fatigue, weakness, HA, weight gain

Signs:

  1. HTN
  2. Central obesity
  3. Purple stretch marks
  4. Muscle weakness
  5. Thin skin
  6. Hirsutism

“cushingoid”
Cataracts, Ulcers, Skin: (striae, thinning, bruising), Hypertension/ hirsutism/ hyperglycemia, Infections, Necrosis, Glycosuria, Osteoporosis, obesity, Immunosuppression, and Diabetes

32
Q

Lab findings for cushing syndrome

A

Hyperglycemia
Hyperlipidemia

  • commonly caused by corticosteroids/excess cortisol
  • need more E, gluconeogenesis, break down lipids - find in blood
33
Q

Adrenal incidentaloma

A

Frequent finding on abdominal imaging

  • usually benign
  • usually non functioning
34
Q

Benign vs malignant adrenal incidentaloma

A

benign

  • High lipid CT scan (low HU)
  • Low uptake FDG PET

Malignant tumor

  • Low lipid (high HU)
  • High uptake FDG uptake
35
Q

Surgical Management of adrenal incidentaloma if…?

A

Surgical removal:

  1. size >4.5 cm
  2. Progressive growth
  3. Hormone secretion

*note: malignant adrenal tumors are ~ 6cm

DEMS Unit 3 (26 decks)

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