ENDO-Adrenal

Question 1

Which adrenal layer secretes catecholamines (epinephrine & norepinephrine)?

Answer 1

medulla (inner)

richly innervated, extension of sympathetic nervous system

Question 2

Which layer Secretes steroid hormones

Answer 2

adrenal Cortex (outer)

Question 3

List the 5 steroid hormone groups based on their receptor binding sites

Answer 3

1] Mineralocorticoids: Aldosterone, 
2] Glucocorticoids: Cortisol, 
3] Androgens: Testosterone, DHEA, 
4] Estrogens: Estradiol, estrone, 
5] Progestins: progesterone- corpus luteum

Question 4

Descibe the HPA axis

Answer 4

Stress -> 
hypothalamus -> 
CRH -> 
Anterior Pituitary -> 
ACTH -> 
adrenal glands -> cortisol

Question 5

HIGH ACTH

LOW serum CORTISOL

Answer 5

Primary adrenal insufficiency
pituitary is pumping out lots of ACTH
adrenal gland is not responding by NOT making cortisol, problem is the adrenal

Question 6

LOW ACTH

LOW serum cortisol,

Answer 6

Secondary adrenal insufficiency

pituitary is not responding to feedback signal of low cortisol
problem is the pituitary

Question 7

PT c/o Weakness, abdominal pain, fever, confusion, N/V/D.

PE/Vitals: Low BP, dehydration; skin pigmentation

Answer 7

Acute (adrenal crisis) Adrenal Insufficiency

Emergency caused by cortisol insufficiency.

Question 8

PT c/o Weakness, easy fatiguability, anorexia, weight loss, N/V/D. abdominal pain; MSK pains; amenorrhea,

PE/Vitals Sparse axillary hair, increased skin pigmentation (esp at creases, pressure areas, nipples),
Low BP,
small heart -quiet sounds

Answer 8

Chronic (Addison’s disease) Adrenal Insufficiency

Question 9

Describe the causes of Primary Adrenal Insufficiency

Answer 9

1] Autoimmune diseases, 
2] Adrenal infections and inflammation, 
3] Bilateral metastases, 
4] After adrenalectomy, 
5] Adrenal hemorrhage or necrosis,
 6] Idiopathic,
 7] Drug-induced, 
8] Congenital disorders

Question 10

Describe the causes of Secondary Adrenal Insufficiency

Answer 10

1] Pituitary or hypothalamic tumor,
2] Pituitary irradiation, surgery or brain trauma,
3] Pituitary infections, inflammation, hemorrhage or necrosis,
4] Acute interruption of prolonged glucocorticoid therapy, 5] Acute adrenal crisis (shock syndromes)

Question 11

PT c/o Weakness, abdominal pain, fever, confusion, N/V/D.

PE/Vitals: Low BP, dehydration; skin pigmentation

What is next step to check?

Answer 11

ADDison Adrenal Insufficiency -cortisol and aldosteronelow
1] CMP with high K+, low Na+, high Ca2+, high BUN,
2] CBC anemia, neutropenia with lymphocytosis, and eosinophilia (chronic),

3] Low plasma cortisol at 8:00am

4] High plasma ACTH in primary adrenal disease

Question 12

PT c/o Weakness, abdominal pain, fever, confusion, N/V/D.

PE/Vitals: Low BP, dehydration; skin pigmentation
Describe the diagnositic test

Answer 12

secondary Adrenal Insufficiency
Cosyntropin stimulation test: Synthetic ACTH given parenterally;

draw blood 30-60 min later;

failure of serum cortisol to rise is POSTIVE FOR PRIMARY- adrenal not responding
IF give DEXA(cortisol) ACTH still stays high, then pituitary

Question 13

What is treatment for Adrenal Insufficiency

Answer 13

1] Replace cortisol with hydrocortisone (or other form),

2] Treat infections aggressively; stress dosing appropriate

Question 14

Pt C/o poor wound healing, psych changes,

Obj-“moon face,” acne, “buffalo hump,” supraclavicular fat pads, protuberant abdomen, thin extremities

PE/Vitals
Central obesity, muscle wasting, thin skin, hirsutism, purple striae, Osteoporosis, HTN,

Answer 14

Cushing’s Syndrome-Due to excess corticosteriods

Massive fat redistribution

Question 15

What are some reproductive dysfunction of Cushing’s Syndrome

Answer 15

Oligomenorrhea/amenorrhea, impotence

Question 16

Describe the other dysfunctions of Cushing’s Syndrome

Answer 16

1] Weakness, backache, HA, polyuria, polydipsia, 2] HTN, osteoporosis, bone AVN, nephrolithiasis, 3] Decreased concentration, mood lability or psychosis

Question 17

What would you order first and find for the next stepss of Cushing’s Syndrome

Answer 17

#1] Late evening salivary cortisol level, 
2] 24 hour urine for free cortisol, 
3] Low-dose dexamethasone suppression test 

4] CMP-Impaired glucose tolerance and insulin resistance, hyperglycemia; hypokalemia (normal sodium)
5]CBC Leukocytosis, lymphocytopenia

Question 18

What are the requirements for diagnosis of Cushing’s Syndrome?

Answer 18

1] Cortisol levels should be checked at least twice,

2] At least two of these tests should be abnormal

Question 19

What is the next step once hypercortisolism is confirmed

What would findings suggest?

Answer 19

plasma ACTH is ordered to find the cause

low ACTH; high serum cortisol,
high cortisol shuts off ACTH production from pituitary, so cause is adrenal tumor

Question 20

If after dexa test, cortisol is till high, ACTH is high then…What is condition?

Answer 20

Cushing’s disease ***
high serum cortisol, high ACTH; high cortisol does not shut off ACTH

pituitary, caused by benign pituitary adenoma

Question 21

What is the next step in management if the patient has Cushing’s disease?

Answer 21

Refer to endocrinology for CRH stimulation test to determine if cause is hypothalamus or pituitary,

Question 22

What are the classic signs and sx of Primary Hyperaldosteronism

Answer 22

PE/Labs:HTN (Resistant HTN primary reason to consider this dx),
hypokalemia
Elevated plasma and urine aldosterone
low plasma renin level- NOT kidneys affectin Aldo

Pt-Polyuria, polydipsia, muscular weakness

Question 23

What are the most common subtypes of Primary Hyperaldosteronism? What test to confirm?

Answer 23

1] aldosterone-producing adenoma and
2] bilateral idiopathic hyperaldosteronism
Adrenal CT scan

Question 24

Describe the treatment of Primary Hyperaldosteronism

Answer 24

adrenalectomy

Question 25

Pt c/o Attacks of HA, perspiration, palpitations, tachycardia, anxiety,

Vital- HTN

Answer 25

Pheochromocytoma

Tumor in adrenal medulla; rare cause of HTN

Question 26

Describe the HTN in Pheochromocytoma

Answer 26

may be sustained, resistant to therapy or paroxysmal, esp in relation to stress

Question 27

Pt c/o Attacks of HA, perspiration, palpitations, tachycardia, anxiety,

Vital- HTN
What is the work up?

Answer 27

Pheochromocytoma
URine- elevated catecholamines or metanephrines;

CBC-plasma fractionated free metanephrines most sensitive but many false positives

Question 28

What is next step in management if catecholamines or metanephrines positive?

Answer 28

Refer to Endocrinology

Followed by imaging of adrenals (CT or MRI)

Question 29

treatment of Pheochromocytoma

Answer 29

surgical resection of tumor

Question 30

When should you refer to an endocrinologist?

Answer 30

1] If positive, refer to Endocrinology,
2] If you’re not sure, refer to Endocrinology,
3] Treatment and follow up will be done by the Endocrinologist