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Pheo, Ca++, adrenal

Clinical Medicine II

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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