Unrein Cushing CIS

Question 1

Addison’s. What would serum cortisol look like?

Answer 1

low basal level of cortisol secretion

Question 2

how can someone be physiologically normal in their cortisol metabolism yet have either abnormally high or low levels of serum cortisol?

Answer 2

it travels bound to albumin

pregnancy– increased serum proteins/ albumin

severe illness in the ICU/ cachexia– decreased serum proteins/ albumin

Question 3

how to dx Addison’s disease?

Answer 3

cosyntropin stimulation test

primary adrenal insufficiency– serum cortisol levels do not increase in response to ACTH

secondary adrenal insufficiency- serum cortisol levels do increase in response to ACTH

Question 4

most common form of adrenal insufficiency?

Answer 4

exogenous steroids

feedback mechanisms not working

Question 5

distinguishing biochemical features/ hallmarks of adrenal insufficiency?

Answer 5

hyperkalemia
hypoglycemia
hyponatremia,
metabolic acidosis

clinical feature include volume depletion and circulatory collapse in severe cases

Question 6

how would you distinguish between primary adrenal insufficiency and secondary adrenal insufficiency based on clinical presentation?

Answer 6

secondary adrenal insufficiency does not have the hyperpigmentation nor the severity of electrolytes abonrmalities;
precursor to melanocyte stimulating hormone and CTH are the same.
Primary insufficiency leads to over-production of acth and its precursor through this common pathway. Aldosterone is not affected by ACTH; it is mainly driven by the renin-angiotensin system, maintaining some of the electrolyte balance.

Question 7

difficult-to-control blood pressure and hypokalemia. What might this be?

Answer 7

mineralocorticoid excess

Question 8

primary glucocorticoid deficiency presentation

Answer 8

would expect hyperpimented skin, hyperkalemia, hyponatremia, hypoglycemia, volume depletion and hypotension

Question 9

Glucocorticoid excess presentation

Answer 9

would expect truncal obesity, significantly elevated serum glucose, hypokalemia, hypernatremia, weight gain (obesity) and thin, easily-bruised skin

Question 10

mineralocorticoid deficiency presentation

Answer 10

this i arare, would present with hyperkalemia and bradycardia due to the elevated potassium, hyponatremia, hypotensiona nd a normal glucose

Question 11

mineralocorticoid excess

Answer 11

would expect hypernatremia, hypokalemia, BP resistant to treatment. Glucose is normal. This is a direct cause of a metabolic alkalosis because of Na_ retention at the expense of K_ and H_

Question 12

differences between low dose and high dose dexamethasone suppression test?

Answer 12

low dose - distinguishes adrenal excess from someone normal (just fat)

high dose- distinguishes someone with primary versus exogenous sources of ACTH

Question 13

cosyntropin stimulation test

Answer 13

used to assess adrenal reserve and differentiate between primary and secondary causes of adrenal insufficiency, not adrenal excess, and measure the changes in serum cortisol

Question 14

serum AM cortisol level

Answer 14

measures total AM cortisol both protein bound and free cortisol. It could be affected by teh exogenous estrogens and other things that affect protein metabolism

Question 15

24-hour urine free cortisol level

Answer 15

the first best screening tool to evaluate free cortisol excess

Question 16

high dose dexamethasone suppression test

Answer 16

used to differentiate pituitary vs extra pituitary sources of excess ACTH secretion

Question 17

proximal muscle weakness

Answer 17

can be caused by adrenocortical excess

but also many other things like lambert-eaton syndrome, MSK stuff, many others.

Question 18

guy with COPD, hoarse, new cough, high urine cortisol, on steroids. What should we do?

Answer 18

CT the chest - some clinical features of malignancy of the upper chest. If adrenal excess, more likely an ACTH producing tumor than a primary effect of the metastasis on adrenal glands

Question 19

guy with pyelonephritis and COPD, every time try to decrease steroids, he has exacerbations of his COPD> Upon hospitalization in addition to antibiotics for hte pyelonephritis you should

Answer 19

administer a stress dose of steroids; he’s sick and needs extra steroids because his adrenal glands are suppressed

Question 20

stress dose of steroids

Answer 20

suppressed adrenal pituitary axis cannot respond physiologically to stress

patient gets sick, give them extra

Question 21

how long is someone considered to have adrenal suppression after a prolonged course of steroids?

Answer 21

one year

Question 22

why is it important to have an intact adrenal pituitary axis in place before starting thyroid replacement?

Answer 22

thyroid picks up the metabolic rate
renal metabolism of cortisol will increase
could precipitate an adrenal crisis and circulatory collapse in a pt that doesn ot have n intact adrenal pituitary axis and therefore unable to respond to stress

Question 23

someone with hypertension and high sodium has been seeing a chinese herbalist for depression. What might be going on?

Answer 23

many chinese medicines have glycyrrhizic acid in them (licorice)
inhibits degradation of cortisol

same consequences as excess cortisol

serum aldosterone and renin would be low because of excess glucocorticoids in the system (they have mineralocorticoid properties)

Question 24

guy with sore throat, purpuric rash and palms and soles and headache. Hypotension and unconscious, not vacced. What’s up?

Answer 24

probably neisseiria meningitis
–> waterhouse friedrichson syndrome
(bilateral adrenal hemorrhage)

Question 25

Waterhouse Friederichsen syndrome

Answer 25

bilateral adrenal hemorrhage

associated with neisseria meningitids

Question 26

clinical approach to waterhouse friedrichson syndrome?

Answer 26

abx and cortisol

Question 27

guy has fatigue after 10 yrs ago transsphenoidal hypophysectomy- removal of pituitary adenoma. Has small testes. What test should we order for his fatigue?

Answer 27

serum free cortisol and free T4;

all pituitary hormones are pointless here because there’s no pituitary and they’re probably on replacement hormones anyway