Adrenal disorders

Question 1

In terms of adrenal disorders, what should we be worries about

Answer 1

Deficiencies in cortisol, aldosterone, not androgens. Deficiency in androgens is more associated with the gonads.

Question 2

What do we have to measure and why to diagnose Addison’s

Answer 2

A high ACTH is diagnostic of Addison’s. CRH would also be high, but it is harder to measure as it is in the hypothalamus of the brain, hence we measure ACTH in the blood.

Question 3

Which areas do we look for hyperpigmentation to diagnose Addison’s

Answer 3

Buccal mucosa, as this is an area that is not usually tanned normally.

Question 4

What else is diagnostic of Addison’s

Answer 4

Low sodium with a high potassium. This results in hypotension.

Question 5

What is meant by postural hypotension

Answer 5

Dizziness when standing

Question 6

Describe the synacthen test

Answer 6

A baseline sample of blood is collected for cortisol and ACTH measurements (must be done at 9.00AM when cortisol levels are highest). In Addisonian patients, you would expect cortisol to be low and ACTH to be high. A subcutaneous or intramuscular injection of 250mcg SYNthetic ACTH is administered and blood samples taken 30-60 minutes later. In patient’s with Addison’s disease there will only be a minimal rise in cortisol levels.

Question 7

How can postural hypotension be diagnosed

Answer 7

Measure BP lying down, measure BP standing up, you will see a drop.

Question 8

Describe how Cushing’s can lead to secondary diabetes.

Answer 8

Cortisol stimulates gluconeogenesis so the blood glucose level rises (secondary diabetes).

Question 9

What tests should be performed regarding the patient’s polyuria and polydipsia

Answer 9

Fasting glucose test- urine dipstick.

Question 10

What else can we measure to monitor how well diabetes is being managed as well as to diagnose diabetes

Answer 10

HbA1C- glycated Hb.
bA1c
mmol/mol
%

Normal
Below 42 mmol/mol
Below 6.0%
Prediabetes
42 to 47 mmol/mol
6.0% to 6.4%
Diabetes
48 mmol/mol or over
6.5% or over

Question 11

Describe proximal myopathy

Answer 11

Becoming tired and weaker when completing normal tasks, such as walking up the stairs. Caused by increased protein catabolism

Question 12

How would you describe the skin of someone with Cushing’s syndrome

Answer 12

Plethoric- red and flushed

Question 13

How do the striae of a patient with Cushing’s differ to post-partum stretch marks

Answer 13

Cushing’s- red, wide and tender

Pregnancy- pale

Question 14

Why is a drug history important in the assessment of Cushing’s

Answer 14

To ensure that the symptoms are due to Cushing’s and not due to taking steroids.
Ask about over and under the counter medications
Remember skin creams and inhalers contain steroids- ask about these

Question 15

Why do patient’s with Cushing’s have poor wound healing

Answer 15

The anti-inflammatory response seen in the presence of excess glucocorticoids.

Question 16

Why do patients with Cushing’s gain weight

Answer 16

Increased lipogenesis
Increased insulin to counteract hyperglycaemia- insulin results in lipogenesis
Hypertension- increased mineralocorticoid activity leads to fluid retention- which could contribute to weight gain.

Question 17

Describe how Conn’s syndrome is diagnosed

Answer 17

Conn’s syndrome usually occurs from a unilateral adrenal tumour, but sometimes patients have bilateral adrenal hyperplasia. Tumours originating in the zona glomerulosa are not under control of the renin-angiotensin system and consequently can secrete large amounts of aldosterone. To confirm we measure aldosterone levels under suppressed renin levels (induced by a saline infusion).

Question 18

How do we treat Conn’s syndrome

Answer 18

Several anti-hypertensive agents as it can be difficult to adequately control their raised BP. They are also often on potassium supplements in view of their profound continuous loss of potassium