What lab and physical exam findings you make you suspect each of the following problems?



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Katie Young

What lab and physical exam findings you make you suspect each of the following problems?





Physical exam findings

Lab findings

Addisonian crisis

Hypotension-shock-coma, fever, dehydration, nausea-vomiting, weakness, hyperkalemia, hypoglycemia, skin pigmentation (GIVE IV CORTISOL OR YOU WILL BE SUED)

Low glucocorticoids, low glucose, ↑ ACTH/MSH , low mineralcorticoids (aldosterone), ↓ Na+, ↓ BP, ↑ K+, acidosis due to hyperkalemia;
In secondary, there will be low ACTH and no skin pigmentation

Hyperaldosteronism

(see conn’s syndrome);

See conn’s syndrome; if secondary to a renin tumor then see ↑ renin and ↑ aldosterone

Cushing’s syndrome

Htn, weight gain, truncal obesity, moon faces, buffalo hump, weakness, diabetes/glucose intolerance, osteoporosis, pink skin striae, ↑ infections, mental disturbances

Cushing’s disease due to ACTH tumor in pituitary (↑ ACTH, ↑ cortisol, aldosterone, androgens); cushin’s syndrome- ↓ ACTH, ↑ cortisol or if small cell CA lung then ↑ acth (similar to cushing’s disease)

In all 24 hr urine free cortisol is ↑;


Booth says no clinically useful and do a CT scan, but could see on boards

Low dose dexamethasone test- if cortisol not suppressed then cushing’s syndrome do high dose dexamethasone for cause: ↑ ACTH, suppression= pituitary cushings; ↑ ACTH, no suppression= ectopic ACTH tumor; ↓ ACTH, no suppression= adrenal cushing’s



Primary hyperparathyroidism

Bones, stones, abdominal groans, psychic moans (osteoporosis, osteitis fibrosa cystic, kidney stones, peptic ulcer/pancreatitis, depression and seizures

Serum Ca ↑, ↓ phosphate, ↑ PTH; PRAD 1 version on chr. 11- overexpression of cyclin D1; generally only 1 parathyroid gland is hyperplastic

Secondary hyperparathyroidism

Due to renal failure;renal osteodystrophy

↓ calcium, ↑ serum phosphate, ↑ PTH due to ↓ vitamin D (all 4 parathyroid glands are hyperplastic

Grave’s disease

Women 20-40, hyperthyroidism, ophthalmopathy, dermopathy (pretibial leg edema); hypermetabolism, nervousness, cardiac arrhythmia/cardiomegaly, rapid pulse, weight loss, diarrhea, weakness, heart intolerance, sweating, emotional lability, hand tremors, eye changes

↑ free T4, low or undectable TSH; TSI thyroid-stimulating immunoglobulins

Primary hypothyroidism

Infants= cretinism (MR, large tongue, short); adults= myxedema (non-pitting edema); fatigue, cold intolerance, overweight, periorbital edema, thick dry skin, constipation, flabby enlarged heart, mental slowness, psychosis

↓ free T4, ↑ TSH (best screen)

2ndary (pituitary) hypothyroidism

See primary hypothyroidism

↓ free T4, but normal TSH do TRH stim test: TSH remains low

3ary (hypothalamus) hypothyroidism

See primary hypothyroidism

↓ free T4, but normal TSH do TRH stimulation test: TSH ↑s

Hashimoto’s disease

Women 45-65, hypothyroid goiter, autoimmune association, SLE, RA, DM

Antimicrosomal antibodies (Ab to thyroid peroxidase), antithyroglobulin antibodies

Diabetes insipidus

Polyuria, polydipsia, maybe associated with head injury

HYPERnatremia and dehydration, low serum osmols

SIADH

Paraneoplastic syndrome from small cell lung cancer, others; cerebral edema and dysfunction

HYPOnatremia, inappropriate ↑ in urine Na and osmols

Adrenogenital syndrome

Suspect in any newborn w/ refractory dehydration and sexual differentiation abnormality with ambiguous genitalia

Defective cortisol synthesis causes ↑ acth (bilateral hyperplasia); androgen production is ↑; if 21 hydroxylase deficiency (↓ na+, ↓ BP, ↑ K+, acidosis) due to no cortisol and no mineral corticoids

Empty sella syndrome

Visual field defects (bitemporal hemianopsia): local mass effect

↓ in all anterior pituitary hormones (TSH, ACTH, GH, FSH/LH)

Somatotrophic adenoma

Gigantism in kids; acromegaly in adults (large head, hands, feet, jaw, large tongue, enlarged soft tissue, diabetes /chf/ htn/ gonadal dysfunction

Failure to suppress GH after oral glucose load

Conn’s syndrome

Adrenal adenoma of the glomerulous layer; hypertension, signs of metabolic alkalosis

↑ Na, ↑ water, ↓ K+, ↓ renin (alkalosis due to hypokalemia)



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