Disorders of the Adrenal Glands

Question 1

clinical manifestations (S&S) due to hypercortisolism (excessive glucocorticoids)

Answer 1

cushing syndrome

Question 2

what is the most common cause of cushing syndrome?

Answer 2

exogenous steroid drugs

Question 3

what is the most common cause of spontaneous cushing syndrome?

Answer 3

cushing disease

Question 4

what is the 2nd most common cause of cushing syndrome?

Answer 4

adrenal tumor

Question 5

ACTH hypersecretion by the pituitary due to very small benign pituitary adenoma

Answer 5

cushing disease

Question 6

a patient presents with central obesity, moon face, buffalo hump, purple striae, slow wound healing, muscle weakness, depression, hypertension, DM, menstrual irregularities, and decreased libido. what are they likely experiencing?

Answer 6

Cushing syndrome

Question 7

what are 2 screening tests for Cushing syndrome?

Answer 7

dexamethasone suppression test
24 hr urine of cortisol and creatinine

Question 8

what level of ACTH after a dexamethasone suppression test would indicate positive Cushing syndrome?

Answer 8

over 5

Question 9

where is the problem if serum ACTH is low? what would we order?

Answer 9

adrenal glands
CT of adrenal

Question 10

where is the problem if serum ACTH is high? what would we order?

Answer 10

pituitary gland
MRI of pituitary

Question 11

what are 2 things that could cause high serum ACTH?

Answer 11

pituitary tumor
ectopic tumor

Question 12

what would labs look like in Cushing syndrome? (5)

Answer 12

elevated serum + urine cortisol
ACTH varies
glycosuria
leukocytosis
hypokalemia

Question 13

what is the treatment for Cushing Disease/ACTH dependent?

Answer 13

transphenoidal selective resection of pituitary adenoma

Question 14

what is the treatment for an adrenal adenoma/ACTH independent?

Answer 14

unilateral adrenalectomy

Question 15

what can patients develop with resection of pituitary, ectopic tumor, or adrenalectomy? what will the patient need?

Answer 15

cortisol withdrawal
hydrocortisone

Question 16

what is the treatment for hypercortisolism when surgery is delayed, CI, or unsuccessful?

Answer 16

“block and replace”

adrenal enzyme inhibitor (ketoconazole) - block

hydrocortisone - replace

Question 17

when the adrenal cortex is absent, destroyed, or dysfunctional and cannot make cortisol or aldosterone

Answer 17

primary adrenal insufficiency (AKA Addison Disease)

Question 18

what is the most common cause of Addison Disease in the US?

Answer 18

autoimmune destruction

Question 19

what is the most common cause of Addison Disease in the rest of the world?

Answer 19

infectious TB

Question 20

a patient presents with fatigue, anorexia, N/V/D, headache, abdominal pain, weight loss, arthralgias, depression, and salt cravings. they also have hypotension and tachycardia. what are they likely experiencing?

Answer 20

primary adrenal insufficiency (Addison)

Question 21

what symptom of primary adrenal insufficiency may precede all other symptoms by months to years?

Answer 21

hyperpigmentation

Question 22

what causes hyperpigmentation in Addison’s disease?

Answer 22

excess ACTH on melanocytes

Question 23

what will labs look like in a patient with primary adrenal insufficiency? (4)

Answer 23

low cortisol
high ACTH
low Na
high K

Question 24

how would DHEA and PRA present in a patient with primary adrenal insufficiency?

Answer 24

low serum DHEA
elevated PRA

Question 25

what diagnostic would we want to get if the primary adrenal insufficiency is not due to an autoimmune cause?

Answer 25

chest CT

Question 26

what is the imaging of choice to evaluate adrenal insuffiency?

Answer 26

CT adrenals

Question 27

what imaging is helpful in diagnosing the etiology of adrenal disease?

Answer 27

CT adrenals + FNA

Question 28

what will be found in a CT adrenals + FNA if the adrenal insufficiency is due to an autoimmune cause?

Answer 28

lymphocytes

Question 29

what will be found in a CT adrenals + FNA if the adrenal insufficiency is due to TB?

Answer 29

granulocytes

Question 30

what will be found in a CT adrenals + FNA if the adrenal insufficiency is due to a neoplasm?

Answer 30

mets

Question 31

what will be found in a CT adrenals + FNA if the adrenal insufficiency is due to a hemorrhage?

Answer 31

blood

Question 32

low ACTH, normal pigmentation and normal aldosterone production indicates what?

Answer 32

secondary adrenal insufficiency

Question 33

what is the treatment for all forms of adrenal insufficiency?

Answer 33

glucocorticoid replacement

Question 34

what specific medications can be used to treat chronic primary adrenal insufficiency? (3)

Answer 34

hydrocortisone dexamethasone prednisone

Question 35

what medication can be used for a patient with primary adrenal insufficiency that has hypotension, salt cravings, or hyponatremia?

Answer 35

fludrocortisone (mineralcorticoid replacement)

Question 36

what can be given to women with primary adrenal insufficiency + impaired mood or sense of well being, despite optimal glucocorticoid and mineralcorticoid replacement?

Answer 36

DHEA

Question 37

what should be done when a patient with adrenal insufficiency develops a febrile illness, needs a surgical procedure, or has an increased stress like serious illness or divorce?

Answer 37

give 2-3 times usual maintenance glucocorticoid dose for 3 days

Question 38

acute adrenal insufficiency = _____ = _____

Answer 38

adrenal crisis emergency

Question 39

a patient presents with N/V, abdominal pain, hypotension, fever, hyponatremia, hyperkalemia, and hypoglycemia. what are they likely experiencing?

Answer 39

adrenal crisis

Question 40

what is the treatment for adrenal crisis? (2)

Answer 40

stress dose of IV hydrocortisone (100-300mg) rapid bolus of normal saline

Question 41

what can be given to a patient in adrenal crisis who has hypoglycemia?

Answer 41

normal saline + dextrose

Question 42

what should ALL patients experiencing an adrenal crisis receive?

Answer 42

empiric antibiotics

Question 43

tumor in the adrenal medulla that secretes epinephrine and NE

Answer 43

pheochromocytoma

Question 44

what is the classic triad of symptoms for pheochromocytoma?

Answer 44

headache palpitations diaphoresis

Question 45

why is diagnosis critical in pheochromocytosis?

Answer 45

condition can lead to fatal hypertensive crisis + cardiac arrythmias

Question 46

what will labs look like in pheochromocytoma? (2)

Answer 46

elevated plasma metanephrines during spell high urine catecholamines

Question 47

what diagnostics can we do to look for tumor in adrenal medulla for pheochromocytoma? (2)

Answer 47

abdominal MRI/CT nuclear imaging

Question 48

what is the treatment of choice for pheochromocytoma?

Answer 48

adrenalectomy

Question 49

what is the pre-op treatment for pheochromocytoma (before adrenalectomy)?

Answer 49

alpha blocker OR CCB (10-14 days) BB for tachycardia (AFTER HTN IS RESOLVED)

Question 50

when can a beta blocker be started for a patient with pheochromocytoma PRE-OP?

Answer 50

only after hypertension is resolved