Cushing's, Addison's, SIADH, Diabetes Insipidu Flashcards
Causes of Cushing’s?
ACTH hyper secretion by the pituitary
Adrenal tumors
Chronic administration of glucocorticoids
Causes of Addison’s?
Deficient Cortisol, androgens, aldosterone***
Autoimmune destruction of adrenal gland
Metastatic cancer
Bilateral adrenal hemorrhage
Pituitary failure resulting in decreased ACTH
Signs and symptoms of Cushing’s
central obesity moon face with buffalo hump poor wound healing hrsutism HTN amenorrhea impotence headache polyuria and thirst labile mood frequent infections
signs and symptoms of Addison’s?
hyper pigmentation in buccal mucosa and skin creases
Diffuse tanning and freckles
Orthostasis and hypotension
Scant axillary and pubic hair
Rapid worsening of chronic signs and symptoms
Labs and Diagnostics of Addison’s
Hypoglycemia, hyponatremia, hyperkalemia**
Elevated ESR, lymphocytosis
plasma cortisol < 5 @ 0800
labs and diagnostics of Cushing’s
hyperglycemia, hypernatremia, hypokalemia***
Glycosuria, leukocytosis
Elevated plasma cortisol in the a.m
Dexamethasone suppression test to differentiate cause
Serum ACTH
Management of Cushing’s
Dc medication inducing symptoms Transphenoidal resection of a pituitary adenoma Surgical removal of adrenal tumors Resection of ACTH secreting tumors Manage electrolytes
Management of Addison’s Outpatient
specialist referal
glucocorticoid and mineralcorticoid replacement (hydrocortisone (glucocorticoid effect) and Fludrocortisone (florinef) (mineralocorticoid effect)
Management of Addison’s Inpatient
Hydrocortisone 110-300 IV with NS: replace volume with D5NS at 500 cc/h x 4 hours then taper per condition
Vasopressors usually ineffective
Tx underlying cause-usually infection
Cause/etiology of SIADH
Release of ADH occurs independent of osmolality or volume dependent stimulation
- inappropriate water retention
- tumor production of adh
- skull fractures/head trauma
- cns disorder
- chronic lung dz
Signs and symptoms SIADH
Neurologic changes***: headache, seizure, coma neuro changes r/t hyponatremia*** Decreased DTRs Hypothermia weight gain/edema Nausea, vomiting Cold intolerance
Labs and Diagnostics SIADH
hyponatremia: yet euvolemic
decreased serum osmolality ( 100)
Urine sodium > 20
Renal, cardiac, thyroid function normal
Causes/etiology DI (central)
related to pituitary or hypothalamus damage resulting in ADH deficiency
(various causes including metastatic carcinoma to infection to trauma)
Causes/etiology DI (nephrogenic)
Due to a defect in the renal tubules resulting in renal insensitvity to ADH
- familial x-linked trait
- acquired due to pyelonephritis, K depletion, sickle cell anemia, chronic hypercalcemia, medications (lithium, methicillin etc)
S & S DI
Thirst/craving fluids polyuria and nocturia wieght loss, fatigue ALOC Dizziness Elevated temp tachycardia Hypotension poor turgur and dry mucus membranes
Labs and diagnostics DI
hypernatremia
BUN/Crt elevated
serume osmo > 290
Urine Osmo < 100
urine specific gravity low < 1.005
if central Di is suspected a vasopressin challenge test- 0.05 -0.1 nasally or 1 ug SQ or IV with measurement of urine volume. Test is positive in central DI and negative in nephrogenic DI
-if no apparent cause then MRI to look for mass/lesion
management SIADH
if serum Na > 120 restrict fluids to 1000 ml/24 hours and monitor
-if serum Na 110-120 w/o neuro sxs restric fluids to 500 ml/hr
if serum Na < 110 or neuro sxs replace with ISOTONIC (NS) or HYPERTONIC (3% or 5%) saline and Lasix at 1-2 mEq/hr
-monitor Na, K losses hourly and replace
Management of DI
If serum Na > 150 give D5 W IV to replace 1/2 volume deficit in 12-24 hours: note: more rapid lower of Na can cause cerebral edema
- when Na < 150 substitute 1/2 or .9% NS
- DDAVP 1-4 ug IV or Sq q 12-24 hours for acute situations
- maintenance dose DDAVP is 10 ug every 12-24 hours intra nasally**
Pheochromocytoma
results from excess catecholamine release characterized by paroxysmal or sustained HTN; almost always d/t tumor of the adrenal medulla**
Pheochromocytoma S & S
labile HTN
-diaphoresis, palpitations, tremor, tachycardia, postural hypotension
sounds like hyperthyroidism
but difference is: hypertension or postural hypotension (not a fx of hyperthyroidism)
labile BP is a tip off
pheochromocytoma labs and diagnostics
- TSH normal** (initial test to order to r/o hyperthyroid)
- -plasma-free metanephrines**
a. plasma concentration of normetanephrine > 2.5 pmol/ml OR
b. Metanephrine levels > 1.4 - -assay of urine catecholamines (total and fractionated), metanephrines, vanillylmandelic acid (VMA) and crt. 24 hr urine > 2.2 metanephrine per mg cry AND > 5.5 VMA per mg crt AND > 5.5 ug VMA per crt (test to order in the outpatient setting)*
- CT of adrenals used to confirm and localize tumor
Pheochromocytoma management
Surgical removal of tumor is treatment of choice.
- adrenal adrenergic meds used preoperatively
- postoperatively watch for: hypotension (depleted catecholamines), adrenal insufficiency(hypotension), hemorrhage
post op- watch for hypotension and hemorrhage
steroids cause..:(adrenocorticotropic hormone) cortisol, cortisone, steroid…
transplant patients receive steroids often
- mobilization of breakdown of fat and mobilizes from periphery to abdomen
- suppress inflammatory response
- prevent uptake of glucose by cell (DM picture)
- vasoconstriction (hypertensive in cushing’s)
aldosterone and androgen deficiency
product of aldosterone + androgen = mineralocorticoids.
Which elevated laboratory findings would you expect to find with Adrenal Insufficiency?
Elevated BUN, low Na, high K
How does hyperthyroidism present?
- unintentional weight loss
- increased sweating
- palpitations
- thinning hair
- thyroid gland that is symmetrically enlarged without nodules but with bruit
- some present with new onset A-fib
Initial management of a patient with lowered TSH levels and increased T4 includes?
ppropylthiouracil (PTU) 150mg Q8 hours
Grave’s dz is characterized by what?
- menstrual irregularities
- fatigued and restless
- weight loss with goiter
What are some conditions that predispose people to Cushing’s dz?
- non-small cell lung carcinoma
- benign pituitary adenoma
- adrenal neoplasm
adenocarcinoma of breast is NOT risk factor
A patient presents with low sodium, high potassium, elevated BUN and hypotension. You suspect Adrenal insufficiency. what PE findings would you expect to find
-hyperpigmentation of skin and tachycardia
also hypoglycemia
A woman with dx of thyroid storm and elevated temp. How do you treat and how do you not tx?
Tx- BB and methimazole
not tx: dont give asprin as fever is most likely d/t hypermetabolic state
Acute Adrenal insufficiency is a medical emergency.
Initial management includes:
hydrocortisone 50mg q 6 hours IV or 100mg q 8 hours IV x 7 days
which lab tests diagnose hypothyroidism
Elevated TSH, decreased T3, decreased T4
Diagnosis of adrenal insufficiency is not made by what?
-antiduretic hormone test (ADH). this test is used to determine cause of ADH deficiencies and excesses not adrenal insufficiency
