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Pheo, Ca++, adrenal
Clinical Medicine II
| Question | Answer |
|---|---|
| Sxs episodes from a pheochromocytoma | HA, Diaphoresis, sweating, palpitations |
| Associated sxs of pheochromocytoma | anxiety, tremor, pallor, CP, epigastria pian, flushing (rare), |
| How long do sxs episodes occur | 1hr |
| What resistant problem do we need to keep PCT in mind | resistant HTN |
| Rare, catecholamine-secreting tumor derived from chromaffin cells | pheochromocytoma |
| 6 H’s of Pheochromocytoma | HTN, HA, hyperhidrosis/excessive sweating, Heart consciousness/palpations, Hypermetabolism, Hyperglycemia |
| What is the rule of 10 | 10% for each, familial, malignant, multiple or bilateral, extra-adrenal, childhood onset, recurrence after surgery |
| What % is familial, malignant, multiple etc | all are 10% |
| Do all 6 H’s occur at the same time | no they can vary with the episodes |
| Resistant HTN | HTN that requires 3 or more drugs to control |
| Diagnostic tests | plasma free metanephrines, (99% sensitivity, 89% specificity), Urine metanephrines (24 rh collection) |
| Sympathomemtic amine marker, usually in the breakdown of epi or norepi | metanephrines |
| Issue with the urine metanephrine collection | adherence |
| Chromaffin cells | in the adrenal medulla, secrete catecholamines, epi and norepi |
| Metanephrine | metabolite of epi |
| Diagnostic tests for pheocytochroma | Serum metanephrines, ocassionally urine metanephrines, Confirmation w/ an Adrenal CT or MRI, or MIGB scan (rare), biopsy |
| What scan Is good at looking for tumors in unusal places | MIGB scan (metaiodobenzyl-guanidine) |
| Where would we look for a pheocytochroma | look in the abdomen! |
| Pre-op medical management | if suspect it, send ot an endocrinologist, meds: Alpha blocker, beta blocker (after an alpha blocker) |
| What is special with an intra-operative management tx | continuous arterial-line BP monitoring (central line) |
| Causes of adrenal insufficiency | TB, fungal infx, dzs infiltrating of the adrenal gland, hemorrhage: warfarin/heparin |
| MC cause of adrenal sufficiency | idiopathic, but varies within populations |
| Adrenal insufficiency | addisions disease |
| Excess adrenal hormones | cushings syndrome |
| Secondary causes of adrenal insufficiency | hypopituitarism, suppression of the hypothalamic-pituitary exogenous steroids |
| Why don’t we want abrubtly stop steroids | d/t adrenal sufficiency, can’t die |
| What is classified as a “long time” onsteroids | 2-3 weeks, must taper slowly! |
| What would cause an addisionion crisis | acute exacerbation of chronic adrenal insufficiency, usually cased by sepsis or surgery |
| Is someone is very sick and can’t find out why what do we do | look into adrenal insufficiency |
| Waterhouse-Freiderichsen Syndrome | aka hemorrhagic adrenalitis, or Fulminantmeningococcemia, failure d/t hemorrhage into adrenal glands 2nd to severe bacterial infection, MC meningococcus Neisseria meningtidis |
| MC cause of acute adrenocortical insufficiency | steroid withdrawal |
| 3 MC sxs of adrenal insufficiency | weakness, hypermigmentation of the skin, wt loss |
| Other sxs of adreanal insufficiency | abd pain, salt craving, diarrhea, constipation, syncope, vitiligo |
| Loss of brown color from areas of skin | irregular white patches: vitiligo |
| PE findings for adrenal insufficiency | subtle and nonspecific, Na+ and vol depleation: orthos, HOTN, tachy, hyperpigmentation |
| Dx of adrenal insufficiency | Serum cortisol levels, <10, or <12-13 in ICU, test but administering 250mcg cosyntropin, should see cortisol levels double if normal, adrenal insufficiency, no response, check q30mins for 6rhs |
| Tx of adrenal insufficiency | emergent, IV hydrocortisone, non: oral twice daily, response usually w/I 12 hrs |
| Signs of hyperkalemia | EKG peaked T waves, little to no p waves |
| Primary adrena insuffiency | impairment of adrenal glands, addison’s disease, autoimmune adrenalitis, |
| Secondary adrenal insuffiecncy | d/t impairement pituitary or hypothalamus usually d/t exogenous steroid use |
| Tertiary adrenal insufficiency | d/t hypothalamic dz and ↓ in corticotropin releasing factor (CRF) |
| Excess production of glucocorticoid hormones | cushings disease |
| MC cause of Cushing’s | exogenous steroid replacement |
| Central cause of Cushing’s | pituitary adenoma |
| Adrenal cause of Cushing’s | adrenal adenoma, hyperplasia, malignancy (can be a met from lung?) |
| Sxs of Cushing’s | mood changes, easy brusing, weakness, wt gain, menstral changes, back pain |
| Signs of Cushing’s | truncal obesity, HTN, glucose intolerance, Hirsutism, wide purple abdominal and thigh striae, Moon face, buffalo hump, osteoporosis, myopathy |
| When do sxs of Cushing’s start showing with steroid replacement | 2-3m extremely hungry |
| Screening test for Cushing’s | Dexamethasone suppression test 1mg at 11pm: shows ↓ plasma cortisol in 8am, if high, shows steroids are being made when they shouldn’t be: Cushing’s |
| What radiology tests would we do for Cushing’s evaluation | CT of head: pit adenoma, or Abd CT for adrenal tumor |
| Gigantism and cause | pituitary tumor d/t chronic exposure of GH prior to epiphyseal fusion |
| Acromegaly | ↑ exposure to GH in adults shows large chin, and skull, large hands, large heart and diastolic dysfxn |
| Consequences of gigantism or acromegaly | ↑ complications from hypersomatotrophism, and more mortality and morbidity |
| When/how do we typically diagnose | when pit tumor is aggressive: HA, visual field changes, hypopituitarism, others; large hands, feet and facial features |
| Tx of acromegaly | surgical removal, radiation, medical suppression usually not the best |
| Deficiency in pituitary hormone production | hypopituitarism |
| Panhypopituitarism | all of the pituitary isn’t fxn and all hormones aren’t produced/secreted |
| Causes of hypotpituitarism | tumors, infiltrative (sarcoidosis, histicytosis), infx, ischemia/infarction, iatrogenic, trauma, congenital autoimmune |
| Kallmann syndrome | congenital hypopituitarism |
| Lymphocytic hypohysittis | autoimmune hypopituitarism |
| Lab studies for hypopituitarism | hormone level checks |
| Causes of low serum calcium | renal insuff, hypoalbuminemia, Vit D def, hypomagnesemia, pancreatitis, sepsis |
| Sxs low calcium | vomiting, diarrhea, nervousness, weakness, paresthesias, muscle stiffness and cramps, HA, abd pain |
| Signs for low calcium | tetany, hair loss cataracts papilledema |
| Why vit d def | dt renal insufficiency |
| Why does pancreatitis cause low serum Ca++ | as pancreas becomes inflamed, Ca++ bounds to fat and makes “soap” “saponification” |
| MC low Ca++ | alcoholics |
| Tapping over facial nerve causes grimicing | chvostek’s sign |
| Carpopedal spasm: squeeze hands and can’t release | Trousseau’s sign |
| Tx hypocalcemia | find cause and add calcium/vit D to diet supplementation |
| Causes of hypercalcemia | malignancy, Breast, lung, head, neck renal, hematologic |
| 50% of all hospitalized pt’s w/ hypercalcemia have what | a malignancy |
| Hematolgic causes of hypercalcemia | mutltiple myeloma, Hodgkin’s lymphoma |
| When we see hypercalcemia in a hospitalized pt what should be on our DDx | cancer! |
| Hypercalcemia hyperparathyroidism | hyperPTH will cause |
| MC cause of hypercalcemia | Hyperparathyroidism |
| 2nd hyperparathyroidism | Vit D def, Chronic renal failure, PTH ↑ w/ low vit D: 3rd hyperPTH |
| Sxs of hypercalcemia | nausea, HA, Diarrhea, Anorexia, lethargy pruritus |
| Complications of hypercalcemia | “Stones, bones, moans, psychic groans” |
| MC renal stones | Nephrolithiasis |
| Pseudogout | calcium pyrophosphate (looks like gout but has calcium deposits) |
| GI abd moans d/t Hypercalcemia | PUD: Ca++ stimulates gastrin release , acute pancreatitis: Ca++ activates phospholipases, Constipation: MC |
| Psychic groans w/ hypercalcemia | ALOC, ↓ concentration and memory, personality change, psychosis, depression |
| Tx hypercalcemia | hydrate! Once hydrated give Lasix: pee out Ca++→→ beyond, calcitonin, |
Created by:
becker15
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