NURS 624 Adrenal Disorders Med Exam_questions,answers with rationales Explained

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2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 1/26 PRESCRIPTION [ Back Sims (/e/exams/) Topics (/e/topics/) CME (/c/cme/) + Retry Q & A: Adrenal Disorders You... r Score: 21% Global Avg: 67% Started: 2/15/2020 3:03 PM Scored: 2/15/2020 3:04 PM Time To Complete: 43s All Questions Missed Questions 1. Incorrect Question Tools: Report Question  ę ȧ In which of the following patients with adrenal insufØciency is therapy with Ùudrocortisones necessary? Ə 31-year-old woman with Sheehan syndrome Ǝ 24-year-old woman with type 1 diabetes mellitus diagnosed with autoimmune Addison disease Ǝ 42-year-old man who underwent pituitary surgery for Cushing disease Ǝ 27-year-old man recently diagnosed with empty Sella syndrome Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 2/26 Incorrect Educational Objective: Characterize the therapeutic difference between primary and secondary adrenal insufØciency. Key Point: Replacement with the mineralocorticoid Ùudrocortisones is only necessary for those with primary adrenal insufØciency such as autoimmune Addison disease. Explanation: Fludrocortisone therapy is reserved for patients who have primary adrenal failure, because both cortisol and aldosterone secretions are affected due to destruction of the entire adrenal cortex. Of the cases described, the 24-year-old with autoimmune Addison disease is the only patient with primary adrenal insufØciency. The other patients listed have secondary adrenal failure. In these cases, the reninaldosterone-angiotensin system continues to work normally, making replacement with Ùudrocortisones unnecessary. References: Smith SJ, MacGregor GA, Markandu ND, et al. Evidence that patients with Addison's disease are undertreated with Ùudrocortisone. Lancet. 2014;1(8367):11-14. White PC. Adrenocortical insufØciency. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:2703-2714. 2. Incorrect Question Tools: Report Question  ę ȧ A 56-year-old woman with alcoholic liver disease presents to you with the complaint of being tired but states that she is otherwise healthy. She currently drinks 3 six-packs of beer every day and tells you she is not interested in alcohol cessation. On examination, her height is 5 feet 6 inches, she weighs 186 pounds, and her blood pressure is 147/84 mm Hg. She has a buffalo hump and striae in the abdomen that are pink in color. She is able to stand up after squatting. You test her nonfasting, glucose level, which is 189 mg/dL. On initial work-up, you order a morning cortisol level, which is 16 mg/dL, and an A1c level, which is 7.3%. You conØrm a diagnosis of diabetes, but you are concerned the patient may have Cushing syndrome given her elevated cortisol level. You order a dexamethasone-suppression test (1 mg), the result of which is 14 mg/dL. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 3/26 Which of the following will best rule out the diagnosis of Cushing syndrome for this patient? Ǝ 24-hour urinary cortisol excretion Ə adrenocorticotropic hormone (ACTH) levels Ǝ low-dose dexamethasone followed by corticotropin-releasing hormone (CRH) stimulation Ǝ high-dose dexamethasone test Incorrect Educational Objective: Appropriately test for pseudo-Cushing syndrome. Key Point: Pseudo-Cushing syndrome, or physiologic hypercortisolism, can occur in patients with poorly controlled diabetes and, rarely, alcohol use disorder. A CRH test after administering low-dose dexamethasone may be the most helpful in distinguishing pseudo-Cushing from Cushing syndrome. Explanation: This patient is likely to have pseudo-Cushing syndrome. Depression, obesity, and alcohol use disorder are all conditions that can lead to this diagnosis. It is important to make an appropriate diagnosis to avoid treating a patient who does not have true Cushing syndrome. The best test to distinguish between pseudo-Cushing and true Cushing syndrome is dexamethasone followed by CRH stimulation. This test is performed by giving dexamethasone 0.5 mg every 6 hours for 8 doses followed by CRH 100 mcg given 2 hours after dexamethasone. The test result is conØrmatory for Cushing syndrome if the plasma cortisol level is greater than 1.4 mg/dL 15 minutes after CRH. However, low-dose dexamathasone testing has been shown to be as accurate as testing followed by CRH stimulation in some studies. A high-dose dexamethasone suppression test is used after the diagnosis of Cushing syndrome to distinguish patients with Cushing disease (pituitary hypersection of ACTH), not to diagnose pseudo-Cushing syndrome. Similarly, ACTH levels are obtained after the diagnosis of Cushing syndrome to help differentiate ACTHdependent and ACTH-independent sources of hypercortisolism. Twenty-four-hour urinary cortisol excretion may be elevated in both Cushing syndrome and pseudoCushing syndrome. References: McPherson RA, Pincus MR. Henry's Clinical Diagnosis and Management by Laboratory Methods. 23rd ed., 2016. Nieman LK. Establishing the diagnosis of Cushing’s syndrome. (https://www.uptodate.com/contents/establishing-the-diagnosis-of-cushingssyndrome) Revised June 19, 2015. Accessed July 28, 2017. Stewart PM, Newell-Price JD. The adrenal cortex. In: Melmed S, Polonsky KS. Williams Textbook of Endocrinology. 13th ed., 201S6e: t4h89O-5w5e5n. ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 4/26 Yanovski JA, Cutler GB Jr, Chrousos GP, Nieman LK. The dexamethasonesuppressed corticotropin-releasing hormone stimulation test differentiates mild Cushing's disease from normal physiology. J Clin Endocrinol Metab. 1998;83(2):348- 352. 3. Incorrect Question Tools: Report Question  ę ȧ A 52-year-old man presents to you because he has been having episodes of headache, palpitations, and sweating for the past 6 months. He has attributed them to panic attacks. He recently checked his blood pressure at a local store and found that it was elevated, and that is the reason for today's visit. He also discloses that his grandfather had neuroØbromatosis. As you start examining the patient, he has what he calls a "panic episode," and you notice that his blood pressure is 170/100 mm Hg, his pulse is 124 beats/minute, and he has profuse diaphoresis. This episode lasts for 10 minutes and then his blood pressure drops to 142/84 mm Hg and his pulse decreases to 88 beats/minute. You have a high index of suspicion that this patient may have pheochromocytoma. If done properly, which of the following is most likely to yield this diagnosis? Ǝ magnetic resonance imaging (MRI) of the adrenal glands Ǝ plasma-free metanephrine levels Ə 24-hour urine collection for metanephrines Ǝ clonidine-suppression test Incorrect Educational Objective: Diagnose pheochromocytoma. Key Point: Pheochromocytoma can be diagnosed using 24-hour urine collection of metanephrines or plasma-free metanephrine levels. Plasma-free metanephrine testing is highly sensitive, and it should be used for patients with a high index of suspicion for pheochromocytoma. Explanation: Plasma-free metanephrine testing is recommended to diagnose pheochromocytoma when the pretest probability is high. This patient is experiencing the classic triad of symptoms, with hypertension and tachycardia, andSheatsha Ofamwielynh([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 5/26 neuroØbromatosis, which suggests a possible genetic cause and a high likelihood of pheochromocytoma. During an attack, plasma-free metanephrine testing is highly sensitive (> 97%) and speciØc (> 85%). However, the test is recommended to be done with the patient supine for 30 minutes with an indwelling intravenous catheter, which can be difØcult in outpatient settings. Additionally, the test has a high falsepositive rate (approximately 15%). A 24-hour urine collection for metanephrines (97% sensitive, 89% speciØc) will also show increased metanephrines; the accuracy of the 24-hour urinary levels for metanephrines can be improved by indexing urinary metanephrine levels by urine creatinine levels. This 24-hour urinary metanephrine test is often used as Ørst-line screening for patients, because there is a lower index of suspicion for the disease in most cases, the test is easier to administer, and it has a lower false-positive rate. The clonidine-suppression test is useful for distinguishing between high levels of plasma norepinephrine caused by release from sympathetic nerves and those caused by release from pheochromocytoma. A decrease of less than 50% in plasma norepinephrine levels after clonidine administration is normal, whereas persistent elevations are indicative of pheochromocytoma. References: Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002 Mar 20;287(11):1427-1434. Garg H, Uppal M, Sreedharan SK, Aggarwal S. Laparoscopic management of recurrent pheochromocytoma: a case report. J Minim Access Surg. 2016;12(3):278- 280. Young WF Jr. Clinical presentation and diagnosis of pheochromocytoma. (https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-ofpheochromocytoma) Revised September 20, 2016. Accessed July 28. 2017. Yu R. Pheochromocytoma. In: First Consult. 2012. Accessed April 5, 2017. 4. Incorrect Question Tools: Report Question  ę ȧ A 32-year-old woman with a history of severe asthma presents to you with swelling, redness, fever, and heat in her left leg. You diagnose her with cellulitis and admit her for antibiotic therapy. The patient has had several asthma attacks this year treated with oral corticosteroids, but currently she is asymptomatic and her usual treatment is continued while in the hospital. After being in the hospital for 12 hours, the patient's fever worsens and she starts experiencing nausea and vomiting. She is also complaining of severe right upper-quadrant abdominal pain. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 6/26 On examination, her abdomen is rigid but it is difØcult to elicit pain on any particular quadrant of the abdomen, and bowel sounds are present. Her pulse is 110 beats/minute, blood pressure 95/62 mm Hg, and temperature is 101.2 °F. She tries to sit up but then complains of severe lightheadedness. Which of the following is the most important next step in the treatment of this patient? Ə Administer STAT morphine for the pain and consult a surgeon for a possible acute abdomen. Ǝ Administer STAT intravenous hydrocortisone 50 mg followed by 50 mg every 8 hours. Ǝ Order STAT chemistries and arterial blood gas values. Ǝ Increase the rate of the Ùuids the patient is receiving to 150 cc/hour. Incorrect Educational Objective: Recognize and list the causes and treatment of an adrenal crisis. Key Point: Patients taking long-term steroids are at risk for secondary adrenal insufØciency. They may become underdosed during times of infection or major illness, resulting in an acute adrenal crisis. Treatment involves intravenous hydrocortisone. Explanation: This 32-year-old woman has a history of asthma and presented with cellulitis. Because steroids are commonly used with patients with asthma, these patients are at a higher risk of having iatrogenic adrenal suppression and they are at higher risk for adrenal crisis when acutely ill. In this scenario, the patient's overall condition is worsening and she has presented with Øndings suggestive of adrenal crisis (worsening fever, nausea, vomiting, and abdominal pain mimicking acute abdomen). Under these circumstances, she should receive immediate treatment with STAT intravenous hydrocortisone 50 mg followed by 50 mg every 8 hours. Chemistries, arterial blood gas levels, and an increase in intravenous Ùuids are also appropriate, but they would not be the Ørst step. If conØrmation of adrenal insufØciency is being considered, then dexamethasone can be administered instead of hydrocortisone to prevent altering results for cortisol levels. Dexamethasone can be administered immediately and blood drawn once therapy is initiated. References: Michels A, Michels N. Addison disease: early detection and treatment principles. Am Fam Physician. 2014;89(7):563-568. Nieman LK. Clinical manifestations of adrenal insufØciency in adults. (http://www.uptodate.com/contents/clinical-manifestations-of-adrenalinsufØciency-in-adults) Revised March 8, 2017. Accessed July 28, 2017. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 7/26 5. Incorrect Question Tools: Report Question  ę ȧ Which of the following is recommended for evaluating the possibility of Cushing syndrome? Ǝ 24-hour urine-free cortisol Ǝ dexamethasone-suppression test (1 mg) Ə insulin-tolerance test Ǝ Either 24-hour urine free cortisol or dexamethasone-suppression test Incorrect Educational Objective: Identify screening methods for Cushing syndrome. Key Point: Whether to use just the dexamethasone suppression test or both that test and the 24- hour urine free cortisol test should be determined by whether one is attempting to rule out Cushing syndrome (single test negative) or to conØrm the diagnosis (both tests positive) Explanation: Either the overnight dexamethasone suppression or the 24-hour urine free cortisol test can be used to screen for Cushing syndrome. Whichever test is performed, a negative result need not be conØrmed with a negative 2 test. However, when the clinical Øndings strongly suggest Cushing syndrome, a positive Ørst test should be followed by the 2 .; positive results from both tests are considered conØrmatory. Persistent elevated excretion higher than 300 µg per 24 hours represents a positive urine free cortisol test. References: Ceccato F, Boscaro M. Cushing's syndrome: screening and diagnosis. High Blood Press Cardiovasc Prev. 2016;23(3):209-215. Nieman LK. Cushing's syndrome: update on signs, symptoms and biochemical screening. Eur J Endocrinol. 2015;173(4):M33-M38. Nieman LK, Adrenal Cortex, Goldman-Cecil Medicine, 2016; 227: 1514-1521.e3 nd nd 6. Correct Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 8/26 Question Tools: Report Question  ę ȧ A 47-year-old woman diagnosed with Cushing syndrome presents to you for further work-up. The patient underwent a dexamethasone suppression test as well as a 24-hour urine free cortisol test, the results of which were reported as 350 mg/24 hours (normal < 50 mg/24 hours). You request an adrenocorticotropic hormone (ACTH) level, which is reported at 102 ng/L (normal 9-52 ng/L). Which of the following is considered the gold standard to differentiate a pituitary vs an ectopic source of ACTH? Ə inferior petrosal sinus sampling (IPSS) with corticotropin-releasing hormone (CRH) stimulation Ǝ metyrapone-suppression test Ǝ inferior jugular venous sampling (JVS) with corticotropin-releasing hormone (CRH) stimulation Ǝ high-dose dexamethasone suppression test Correct Educational Objective: Determine the source of the hyperproduction of adrenocorticotropic hormone. Key Point: IPSS with CRH stimulation is the gold standard to differentiate between the pituitary and ectopic production of ACTH in patients with Cushing syndrome. Explanation: Only 1 test has been described as the gold standard to differentiate between an ectopic and a pituitary source of ACTH: the IPSS with CRH stimulation. Because the technique for IPSS is so difØcult, inferior JVS with CRH is an acceptable diagnostic test; however, it fails to yield an appropriate diagnosis approximately in 10% of cases. It can be performed Ørst; however, if a diagnosis is not made, IPSS is required. Neither a high-dose dexamethasone test nor a metyrapone-suppression test will be able to adequately distinguish between ectopic or pituitary sources of ACTH. References: Guo YW, Hwu CM, Won JG, Chu CH, Lin LY. A case of adrenal Cushing's syndrome with bilateral adrenal masses. Endocrinol Diabetes Metab Case Rep. 2016;2016:150118. 7. Correct Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 9/26 Question Tools: Report Question  ę ȧ In a patient with an established diagnosis of Cushing syndrome, an adrenocorticotropic hormone (ACTH) level is drawn and found to be undetectable. Which of the following is the next step in this patient's work-up? Ǝ exploratory surgery of the adrenal glands Ǝ positron emission tomography (PET) Ǝ metyrapone-suppression test Ə computed tomography (CT) of the adrenal glands Correct Educational Objective: Identify adrenal causes of Cushing syndrome. Key Point: Undetectable ACTH in a patient with Cushing syndrome suggests that the hyperproduction of cortisol is occurring in the adrenal gland. In those cases, CT of the adrenal glands is indicated because the most common cause of the disorder is a solitary adrenal adenoma. Explanation: In the diagnostic paradigm for Cushing syndrome, establishing whether the syndrome is ACTH-dependent or ACTH-independent dictates the next step in the work-up. ACTH-dependent means that a pituitary tumor produces ACTH and this, in turn, increases cortisol. ACTH-independent means that the adrenal gland is hyperproducing cortisol (and by negative feedback, ACTH becomes undetectable). The patient scenario described has been established as ACTH-independent Cushing syndrome. Because the vast majority of these cases are due to solitary adrenal adenomas, the next step is CT of the adrenal glands. Exploratory surgery of the adrenal is not recommended because there are noninvasive means to establish a diagnosis. PET is reserved for patients with adrenal carcinoma to detect metastatic disease. A metyrapone-suppression test is not indicated in this setting. References: Aktas GE, Soyluoglu Demir S, Sarikaya A. Bilateral symmetrical adrenal hyper metabolism on FDG PET/CT due to Cushing syndrome in well differentiated neuroendocrine carcinoma. Rev Esp Med Nucl Imagen Mol. 2016;35(2):118-120. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 10/26 8. Incorrect Question Tools: Report Question  ę ȧ A 47-year-old woman with Cushing syndrome needs further work-up. The results of her dexamethasone suppression test were reported as 350 mg (normal range, < 50 mg). Her 24-hour urine free cortisol test is also elevated. You order an adrenocorticotropic hormone (ACTH) level, the result of which is 102 ng/L (normal range, 9-52 ng/L). Which of the following is considered the gold standard to differentiate a pituitary vs an ectopic source of ACTH? Ə high-dose dexamethasone suppression test Ǝ inferior jugular venous sampling (JVS) with corticotropin-releasing hormone (CRH) stimulation Ǝ inferior petrosal sinus sampling (IPSS) with corticotropin-releasing hormone (CRH) Ǝ metyrapone-suppression test Incorrect Educational Objective: Determine the cause of ACTH-dependent Cushing syndrome. Key Point: ACTH-dependent Cushing syndrome can either be due to a pituitary adenoma or ectopic ACTH secretion. The gold standard to differentiate between those causes is CRH stimulation combined with IPSS. Explanation: IPSS with CRH stimulation is the single test that has been described as the gold standard to differentiate between an ectopic and pituitary source of ACTH. Because the technique for IPSS is so difØcult, inferior JVS with CRH is an acceptable diagnostic test; however, it fails to yield an appropriate diagnosis in approximately 10% of cases. It can be performed Ørst; however, if a diagnosis is not made, then IPSS is required. Neither a high-dose dexamethasone test nor a metyrapone-suppression test will adequately distinguish between ectopic or pituitary sources of ACTH. References: Guo YW, Hwu CM, Won JG, Chu CH, Lin LY. A case of adrenal Cushing's syndrome with bilateral adrenal masses. Endocrinol Diabetes Metab Case Rep. 2016;2016:150118. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 11/26 Nieman LK. Establishing the cause of Cushing’s syndrome. (http://www.uptodate.com/contents/establishing-the-cause-of-cushingssyndrome) Revised November 26, 2013. Accessed July 28, 2017. 9. Incorrect Question Tools: Report Question  ę ȧ A 31-year-old man with history of type 1 diabetes mellitus, which he has had since 4 years of age, presents to you for a routine follow-up visit. The patient's glycated hemoglobin level is 7.2%, and he is using an insulin pump to control his diabetes. On physical examination, the patient has a blood pressure of 142/86 mm Hg. This is the Ørst time his blood pressure reading has been elevated. A spot urine albumin/creatinine test performed 1 month ago was 39. You decide to have the patient return 1 week later to recheck blood pressure and review new laboratories. At the next visit, his blood pressure is 146/84 mm Hg and he has a spot urine albumin/creatinine level of 36. His creatinine level is 1.3 mg/dL; it had been 1.1 mg/dL 6 months prior. You start the patient on enalapril and have him return 2 weeks later with blood chemistries. At the next follow-up visit, the patient's blood pressure is now 152/88 mm Hg, his creatinine level is 1.7 mg/dL, and his potassium level is 5.1 mEq/L. Which of the following should be the next step in the treatment of this patient? Ǝ Discontinue enalapril and start verapamil. Ǝ Order gadolinium-enhanced magnetic resonance angiography. Ǝ Discontinue enalapril and order captopril renography. Ə Increase his dose of enalapril. Incorrect Educational Objective: Recognize and diagnose renovascular disease. Key Point: Young patients with worsening blood pressure and renal function after starting therapy with an angiotensin-converting enzyme inhibitor should be evaluated for renovascular disease. The gold standard for diagnosing renal artery stenosis is renal arteriography, although Doppler ultrasonography and computed tomography angiography may also be considered. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 12/26 Explanation: This patient has renovascular hypertension. Clinical Øndings of worsening blood pressure, worsening renal function, and a high potassium level after initiating therapy with an angiotensin-converting enzyme (ACE) inhibitor are all suggestive of this diagnosis. However, to properly treat this patient, the diagnosis needs to be conØrmed. For that, gadolinium-enhanced magnetic resonance angiography is the gold standard. However, caution must be made in patients with reduced kidney function due to possible gadolinium-associated complications such as nephrogenic systemic Øbrosis. Duplex Doppler ultrasonography can also be used, particularly in patients with decreased kidney function, although results are very operator dependent. Spiral computed tomography (CT) with CT angiography is excellent at detecting renovascular disease related to atherosclerosis but less so for Øbromuscular disease. Enalapril should be withheld to prevent further kidney injury in the event MRA conØrms renovascular hypertension. Renograms obtained after administration of captopril may demonstrate the ACE inhibitor-induced decline in glomerular Øltration rate in the stenotic kidney. However, there is varying sensitivity and speciØcity rates in different studies, as well as limited interobserver agreement, to warrant recommending renography to diagnose renovascular disease. Increasing his enalapril or changing the patient to verapamil should not be done. Doing so will allow the condition to worsen. Verapamil may well be appropriate but only after the diagnosis has been established. References: Textor S. Establishing the diagnosis of renovascular hypertension. (https://www.uptodate.com/contents/establishing-the-diagnosis-of-renovascularhypertension) Revised November 18, 2015. Accessed July 28, 2017. Textor S. Evaluation of secondary hypertension. (https://www.uptodate.com/contents/evaluation-of-secondaryhypertension) Revised July 28, 2015. Accessed July 28, 2017. 10. Incorrect Question Tools: Report Question  ę ȧ A 35-year-old man presents with fatigue and lethargy that he says have lasted for 6 months. He has no medical history. He takes a multivitamin but no other medications. He smokes 1 pack of cigarettes every week and drinks 1 glass of wine each night. He does not use drugs. He is the manager at a retail clothing store. His review of symptoms is a notable 15-pound weight loss during the last 6 months. Vital signs are: temperature 37.4 °C, heart rate 95 beats/minute, blood pressure 110/65 mm hg, respiratory rate 14 breaths/minute, and oxygen saturation 99% on room air. Findings on his head, ears, eyes, nose, and throat Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 13/26 examination are normal, as are the results from examinations of his neck, heart, lung, abdomen, and neurologic status. His skin is notable for a tanned appearance. You order laboratory studies that reveal a normal complete blood count, and levels of sodium of 130, potassium of 5.1, chloride of 110, bicarbonate of 25, blood urea nitrogen of 13, creatinine of 0.8, and glucose of 90. His baseline cortisol level is 3 mcg/dL, which is low. About 30 and 60 minutes after the injection of corticotrophin 250 mcg (an adrenocorticotropic hormone [ACTH]), his cortisol level is 4 mcg/dL. What is the most likely diagnosis? Ə Sheehan syndrome Ǝ sarcoidosis Ǝ AIDS Ǝ tuberculosis Ǝ Addison disease Incorrect Educational Objective: Diagnose adrenal insufØciency. Key Point: A poor response to ACTH stimulation (increase < 18 mcg/dL) indicates adrenal insufØciency. A plasma ACTH level would further distinguish primary from secondary causes. Explanation: Chronic adrenal insufØciency is characterized by nonspeciØc symptoms such as fatigue, weight loss, and low energy. Because symptoms are often nonspeciØc, the diagnosis can be elusive. Because of mineralocorticoid deØciency, serum chemistries will often show hyponatremia and hyperkalemia. Skin pigmentation is often dark. The diagnosis can be made with an ACTH stimulation test. A cortisol level is checked 30 to 60 minutes after administration of ACTH. The cortisol level after ACTH should rise to at least 18 mcg/dL. To distinguish between primary and secondary adrenal insufØciency, plasma ACTH levels must be obtained. In cases of primary adrenal insufØciency, the ACTH levels are high, but the adrenal gland is not properly functioning. In cases of secondary adrenal insufØciency, the pituitary is not producing ACTH, and the levels are low or low-normal. Sarcoidosis and tuberculosis can present with similar symptoms,; however, the laboratory values and imaging results would be different. AIDS can affect the adrenal gland as a chronic disease, but also through infection and malignancies. Treatment for HIV infection has greatly reduced this complication. Reference: Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 14/26 Wiebke A. Disorders of the adrenal cortex. In: Longo D, et al, eds. Harrisons Principles of Internal Medicine. 18th ed., 2012. 11. Incorrect Question Tools: Report Question  ę ȧ In a patient with an established diagnosis of Cushing syndrome, an adrenocorticotropic hormone (ACTH) level is drawn and found to be undetectable. Which of the following is the next step in this patient's work-up? Ǝ computed tomography (CT) of the adrenal glands Ǝ exploratory surgery of the adrenal glands Ə metyrapone-suppression test Ǝ positron emission tomography (PET) Incorrect Educational Objective: Examine the role of adrenocorticotropic hormone (ACTH) in determining the cause of Cushing disease. Key Point: Low ACTH levels in patients with Cushing syndrome indicate an adrenal cause. CT of the adrenal glands looking for an adrenal mass is the next step. Explanation: In the diagnostic paradigm for Cushing syndrome, establishing whether the syndrome is ACTH-dependent or ACTH-independent dictates the next step in the work-up. This patient has established ACTH-independent Cushing syndrome. Because the vast majority of these cases are due to solitary adrenal adenomas, the next step is CT of the adrenal glands. Exploratory surgery of the adrenal is not recommended because other noninvasive means exist to establish the diagnosis. PET is reserved for patients with adrenal carcinoma to detect metastatic disease. A metyrapone-suppression test is not indicated in this setting. References: Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 15/26 Aktas GE, Soyluoglu Demir S, Sarikaya A. Bilateral symmetrical adrenal hyper metabolism on FDG PET/CT due to Cushing syndrome in well differentiated neuroendocrine carcinoma. Rev Esp Med Nucl Imagen Mol. 2016;35(2):118-120. Nieman, LK. Adrenal cortex. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016:1514-1521 12. Incorrect Question Tools: Report Question  ę ȧ A 58-year-old man presents to you as a new patient. He has not seen a physician in several years. The patient states that he is getting up at night frequently to urinate, he is thirsty most of the time, and he has blurry vision. He has also been bruising easily and has noticed "stretch marks" in his abdomen. He also says he has noticed that he looks more tanned. On physical examination, his pulse is 82 beats/minute and his blood pressure is 166/92 mm Hg. The abdomen is large with purple striae and his extremities are thin with several ecchymoses. You ask the patient to squat and stand up, but he is unable to stand up without assistance. The patient's skin shows darker pigmentation in his skin-fold areas. His 24-hour urinary free cortisol excretion rate is 4 times the upper limit of normal, and his cortisol level is elevated after a dexamethasone suppression test. A random plasma adrenocorticotropic hormone (ACTH) concentration is high (> 20 pg/mL). Magnetic resonance imaging (MRI) shows an 8-mm-sized pituitary adenoma. His laboratory studies and radiologic diagnostics conØrm a diagnosis of Cushing disease. Which of the following is recommended for this patient? Ǝ adrenalectomy Ə ketoconazole Ǝ trans-sphenoidal microsurgery Ǝ radiosurgery Incorrect Educational Objective: Identify the appropriate treatment for Cushing disease. Key Point: Cushing disease is a pituitary cause of ACTH-dependent Cushing syndrome. Treatment is trans-sphenoidal microsurgery. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 16/26 Explanation: This patient presents with classic symptoms of Cushing disease, including striae and easy bruising. The diagnosis requires 2 different Ørst-line test results to be abnormal: late-night salivary cortisol (2 measurements), 24-hour urinary free cortisol excretion (2 measurements), or an overnight 1 mg dexamethasone suppression test. Plasma ACTH levels can be used to determine if the hypercortisolism is ACTH dependent or not. If plasma ACTH is low (< 5 pg/mL), then the disease is ACTH-independent, and computed tomography should be done to look for adrenal mass. If it is high (> 20 pg/mL), then the disease is ATCH-dependent, and either MRI or further laboratory testing must be done to differentiate between a pituitary adenoma or ectopic ACTH secretion as the cause. For patients with identiØed pituitary adenomas, surgical resection by transsphenoidal microsurgery is the treatment of choice, because it leads to cure in more 95% of cases. Ketoconazole and adrenalectomy are reserved for patients with adrenal tumors that lead to Cushing syndrome (the latter is the treatment of choice). Radiosurgery can be used for pituitary adenomas but is generally reserved for patients who have failed surgical therapy. References: Fathalla H, Cusimano MD, Alsharif OM, Jing R. Endoscopic transphenoidal surgery for acromegaly improves quality of life. Can J Neurol Sci. 2014;41(6):735-741. Nieman LK. Establishing the cause of Cushing’s syndrome. (http://www.uptodate.com/contents/establishing-the-cause-of-cushingssyndrome) Revised November 26, 2013. Accessed July 28, 2017. Nieman LK. Establishing the diagnosis of Cushing’s syndrome. (https://www.uptodate.com/contents/establishing-the-diagnosis-of-cushingssyndrome) Revised June 19, 2015. Accessed July 28, 2017. 13. Incorrect Question Tools: Report Question  ę ȧ A 58-year-old man presents to you as a new patient. He has not seen a physician in several years. The patient states that he is getting up at night frequently to urinate, he is thirsty most of the time, and he has blurry vision. He has also been bruising easily and has noticed he has "stretch marks" in his abdomen (see Figure). Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 17/26 Figure. Reproduced from White GM. RegionalDerm website. (http://regionalderm.com/Regional_Derm/Øles/qr_back.html) He also says he has noticed he looks more tanned. His pulse is 82 beats/minute and his blood pressure is 166/92 mm Hg. Upon examination, his abdomen is large and there are purple striae in his abdomen and back (see Figure), and his extremities are thin with several ecchymoses. You ask the patient to squat and stand up, but he is unable to stand up without assistance. The patient's skin has darker pigmentation in the skin-fold areas. Computed tomography of the abdomen is unrevealing. The results from additional laboratory values and radiologic diagnostics conØrm a diagnosis of Cushing disease. Which of the following is recommended for this patient? Ə adrenalectomy Ǝ trans-sphenoidal microsurgery Ǝ Gamma knife treatment Ǝ ketoconazole therapy Incorrect Educational Objective: Identify an appropriate surgical option for a patient with Cushing disease. Key Point: Cushing disease caused by a pituitary tumor is best treated with surgical resection via trans-sphenoidal microsurgery. Explanation: Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 18/26 For patients with identiØed pituitary adenomas causing Cushing disease, surgical resection by trans-sphenoidal microsurgery is the treatment of choice, and it leads to cure in more than 95% of cases. Ketoconazole therapy and adrenalectomy are reserved for patients with adrenal tumors that lead to Cushing syndrome (the latter is the treatment of choice). Gamma knife treatment can be used for pituitary adenomas but is generally reserved for patients whose disease has failed surgical therapy. Note that Cushing disease refers speciØcally to the condition caused by a pituitary tumor, whereas Cushing syndrome is a more generic name that encompasses all the clinical manifestations of excessive cortisol production. References: Fathalla H, Cusimano MD, Alsharif OM, Jing R. Endoscopic transphenoidal surgery for acromegaly improves quality of life. Can J Neurol Sci. 2014;41(6):735-741. White GM. RegionalDerm website. (http://regionalderm.com/Regional_Derm/Øles/qr_back.html) Accessed July 25, 2017. 14. Incorrect Question Tools: Report Question  ę ȧ A 56-year-old woman with alcoholic liver disease presents to you because she has been tired lately, but otherwise she has no complaints. She currently still drinks 3 six-packs of beer daily and states she is not interested in alcohol cessation. On examination, she is 5 foot, 6 inches, weighs 186 pounds, and has a blood pressure reading of 147/84 mm Hg. She has a buffalo hump and striae in the abdomen that are pink in color. She is able to stand up after squatting. You test her nonfasting, glucose level, which is 189 mg/dL. On initial work-up, you order a morning cortisol level, which is 16 mg/dL, and an A1c level, which is 7.3%. You conØrm a diagnosis of diabetes, but you are concerned the patient may have Cushing syndrome given her elevated cortisol level. You order a dexamethasone-suppression test (1 mg), the result of which is 14 mg/dL. Which of the following will best rule out the diagnosis of Cushing syndrome for this patient? Ǝ intravenous dexamethasone-suppression test Ǝ low-dose dexamethasone followed by corticotropin-releasing hormone (CRH) stimulation Ǝ dexamethasone test (2 mg) Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 19/26 Ə Liddle test (dexamethasone 0.5 mg every 6 hours for 2 days) Incorrect Educational Objective: Recognize the presentation of pseudo-Cushing syndrome. Key Point: A clinical condition resembling Cushing syndrome can be caused by depression, obesity, and alcohol use disorder. The best way to recognize is by administering low doses of dexamethasone followed by CRH stimulation. Explanation: This patient likely has pseudo-Cushing syndrome. Depression, obesity, and alcohol use disorder are all conditions that can lead to this diagnosis. It is important to make an appropriate diagnosis to avoid treating a patient who does not have true Cushing syndrome. The most appropriate test to distinguish between pseudo-Cushing syndrome and true Cushing syndrome is 2 days of dexamethasone followed by a CRH-stimulation test. This test is performed by giving 0.5 mg dexamethasone every 6 hours for 8 doses followed by CRH 100 µg given 2 hours after dexamethasone. The test is conØrmatory for Cushing syndrome if the plasma cortisol level is greater than 1.4 mg/dL 15 minutes after CRH. The other tests listed could also be used, but they are not the most appropriate tests to establish a clear diagnosis. References: Guber HA, Farag AF. Evaluation of endocrine function. In: McPherson RA, Pincus MR. Henry's Clinical Diagnosis and Management by Laboratory Methods. 22nd ed., 2011:365-401.e5. Nieman L. The dexamethasone-suppressed corticotropin-releasing hormone test for the diagnosis of Cushing's syndrome: what have we learned in 14 years? J Clin Endocrinol Metab. 2007;92:2876. Stewart PM, Newell-Price JD. The Adrenal Cortex Williams Textbook of Endocrinology. 2016:489-555. Yanovski JA, Cutler GB Jr, Chrousos GP, Nieman LK. The dexamethasonesuppressed corticotropin-releasing hormone stimulation test differentiates mild Cushing's disease from normal physiology. J Clin Endocrinol Metab. 1998;83(2):348- 352. 15. Incorrect Question Tools:  ę ȧ Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 20/26 Report Question Which of the following patients should not be tested for primary aldosteronism? Ǝ 57-year-old woman with stage 2 hypertension Ǝ 39-year-old moderately obese man with hypertension and sleep apnea Ə 62-year-old man with stage 1 hypertension, currently taking a low-dose diuretic, with a repeated potassium level of 3.2 mEq/L Ǝ 45-year-old man with stage 1 hypertension and repeated potassium of 5.2 mEq/L (normal range, 3.5-5.0 mEq/L) Incorrect Educational Objective: List the recommendations for detecting primary aldosteronism. Key Point: Patients with mild hypertension who lack hypokalemia do not need to be screened for primary aldosteronism. Explanation: Primary aldosteronism results in the hypersecretion of aldosterone, and it is an underdiagnosed cause of hypertension. The classic presentation is a patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. Case Øndings are important, because treatment of the mineralocorticoid excess improves or can even reverse the hypertension, resolving the increased risk of cardiovascular morbidity and mortality. Case-detection testing consists of measuring either the plasma renin activity or plasma renin concentration, as well as the plasma aldosterone concentration. The Endocrine Society recommends case-detection testing for the following patients: Hypertension and spontaneous or low-dose diuretic-induced hypokalemia Moderate hypertension (> 150 mm Hg systolic blood pressure or > 100 mm Hg diastolic blood pressure) Mild hypertension (> 140 mm Hg systolic blood pressure or > 90 mm Hg diastolic blood pressure) resistant to 3 antihypertensive drugs Controlled hypertension (< 140/90 mm Hg) on ≥ 4 antihypertensive drugs Hypertension and adrenal incidentaloma Hypertension and sleep apnea Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (< 40 years) Hypertensive Ørst-degree relatives of patients with primary aldosteronism Older patients with stage 1 hypertension who do not have hypokalemia, or patients with hypertension controlled with up to 3 antihypertensive drugs, do not need to be screened for primary aldosteronism. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 21/26 References: Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101(5):1889-1916. Young WF Jr. Diagnosis of primary aldosteronism. (https://www.uptodate.com/contents/diagnosis-of-primary-aldosteronism) Revised October 19, 2016. Accessed July 28, 2017. 16. Correct Question Tools: Report Question  ę ȧ A 45-year-old man presents to you because of a reduced libido and impotence. He states that he began noticing issues with his libido about 1 year ago but he is more concerned now because he has been noticing that his chest appears to be developing a breast-like appearance (more tissue, darker and larger nipples) and the tadalaØl he is taking for erectile dysfunction does not seem to be helping as well as it did before. He denies any other health issues. On examination, his vital signs are normal and you conØrm the presence of gynecomastia. The testes are small and insensitive. No abdominal masses are palpable. You send the patient for diagnostic testing and discover levels of estrogen of 178 pg/dL (normal range, 13-54 pg/dL), luteinizing hormone of 0.2, follicularstimulating hormone of 0.3, and testosterone of 67 pg/dL (normal range, 250- 800 pg/dL). Computed tomography (CT) shows a 7.3-cm, irregular mass on the right adrenal gland. Which of the following do you recommend to this patient? Ǝ repeat CT in 6 months to monitor mass size Ǝ Øne-needle biopsy of the adrenal mass Ǝ positron emission tomography Ə surgical resection of the mass Correct Educational Objective: Describe the workup and treatment for a large adrenal mass. Key Point: Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 22/26 Adrenal masses with suspicious imaging phenotype or size larger than 6 cm should be resected. Explanation: The patient described has a large (> 6 cm) adrenal mass, which is suspicious for adrenocortical cancer; thus, the patient should undergo resection of the mass. Any incidental mass of the adrenals greater than 6 cm in size or any mass evidenced on workup for a suspected adrenal disorder that is of this size, requires surgical resection. Radiologic characteristics suggestive of malignancy include: Irregular margins Lack of homogeneity Soft-tissue calciØcations visible on CT Hyperintensity compared with liver on T2-weighted magnetic resonance imaging Adrenal nodules with low CT attenuation values (< 10 HounsØeld units) and Øndings on rapid contrast washout (washout more than 50% after 10 minutes) are likely to be benign. Though they are rare, estrogen-producing adrenal tumors can occur and can present as described in this case. References: Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest. 2012;29(4):298- 302. White PC. Adrenocortical tumors. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016; 579: 2726-2727. 17. Correct Question Tools: Report Question  ę ȧ A 52-year-old woman with poorly controlled hypertension is presenting for her annual visit. She does not have any complaints. Her medications are a lowdose hydrochlorothiazide and lisinopril. Her home blood pressure readings reveal systolic pressures in the low 140s mm Hg and diastolic pressures in the normal range. Her vital signs are: temperature 36.9°C (98.4 °F), blood pressure 142/75 mm Hg, pulse rate 86 beats/minute, and respiratory rate 12 breaths/minute. Her body mass index is 24 kg/m . Repeat laboratory studies reveal potassium levels of 3.0 and 3.3 mEq/L. Further testing is ordered. Other laboratory studies are as follows: 2 Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 23/26 Potassium 3.2 mEq/L (3.5-5.0 mEq/L) Plasma renin activity (PRA) 0.7 ng/mL/hour (1.0-4.0 ng/mL/hour) Plasma aldosterone concentration (PAC) 20 ng/dL (5-30 ng/dL) PAC/PRA ratio 28 Which of the following is the most likely diagnosis? Ə primary aldosteronism Ǝ congenital adrenal hyperplasia Ǝ long-term licorice root ingestion Ǝ renovascular disease Correct Educational Objective: Diagnose primary aldosteronism. Key Point: Primary aldosteronism should be suspected when the PRA is suppressed (or the plasma renin concentration is undetectable), the PAC/PRA ratio is above 20, and the PAC is greater than 15 ng/dL. Further testing must be done to conØrm the diagnosis. Explanation: Patients with hypertension and hypokalemia should be evaluated for primary aldosteronism. Testing aids in differentiating patients with primary aldosteronism, secondary hyperaldosteronism, and other causes of mineralocorticoid excess. Initial case-detection testing involves measurements of PRA (or plasma renin concentration) and plasma aldosterone concentration. Both renin and aldosterone levels have diurnal variation, and they are affected by posture; therefore, it is recommended that samples are drawn in the morning in seated patients. Primary aldosteronism should be suspected when the PRA is suppressed below 1.0 ng/dL (or the plasma renin concentration is undetectable), the PAC/PRA ratio is above 20, and the plasma aldosterone concentration is at least 15 ng/dL. Unless the PRA or its concentration is undetectable, further testing with sodium loading and measurement of aldosterone levels are needed to conØrm the diagnosis. Secondary hyperaldosteronism, such as in renovascular disease, should be considered when both the PRA and its concentration and the aldosterone concentration are increased and the PAC/PRA ratio is less than 10. Other causes include diuretic therapy or, rarely, renin-secreting tumors. Suppressed renin and aldosterone levels in hypertensive hypokalemic patients indicate the possibility of nonaldosterone, mineralocorticoid excess. Causes include some types of congenital adrenal hyperplasia, long-term licorice root ingestion, severe Cushing syndrome, and some adrenal tumors. Similar Øndings are seen in Liddle syndrome, a genetic mutation affecting sodium channels of the collecting tubules, that results in increased sodium reabsorption, potassium wasting, and hypertension. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 24/26 References: Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101(5):1889-1916. Stowasser M. Assays of renin-angiotensin-aldosterone system in adrenal disease. (https://www.uptodate.com/contents/assays-of-the-renin-angiotensin-aldosteronesystem-in-adrenal-disease) Revised May 19, 2017. Accessed July 28, 2017. Young WF Jr. Diagnosis of primary aldosteronism. (https://www.uptodate.com/contents/diagnosis-of-primary-aldosteronism) Revised October 19, 2016. Accessed July 28, 2017. 18. Incorrect Question Tools: Report Question  ę ȧ A 35-year-old man presents with fatigue, loss of libido, and lethargy for the last 3 years. He has no medical history. He takes a multivitamin but no other medications. He smokes 1 pack of cigarettes every week and drinks 1 glass of wine each night. He does not use drugs. He is the manager at a retail clothing store. His review of symptoms is notable for a 15-pound weight loss since his last visit 3 years ago. Vital signs are: temperature 37.4 °C, heart rate 95 beats/minute, blood pressure 110/65 mm Hg, respiratory rate 14 breaths/minute, and oxygen saturation 99% on room air. Findings on his head, ears, eyes, nose, and throat examination, as well as examinations of his neck, heart, lungs, abdomen, and neurologic status are all normal. His skin appears tanned, even under his clothes. You order laboratory studies that show a normal complete blood count, sodium level of 130, potassium level of 5.1, chloride level of 110, bicarbonate level of 25, blood urea nitrogen level of 13, creatinine level of 0.8, and glucose level of 90. You suspect adrenal insufØciency. What is the next test to order to conØrm this diagnosis? Ǝ antiadrenal antibodies Ǝ 24-hour urine cortisol excretion Ǝ low-dose corticotrophin stimulation test Ə random serum cortisol and adrenocorticotropic hormone (ACTH) levels Ǝ Plasma cortisol level after infusion of adrenocorticotropic hormone (ACTH) Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 25/26 Incorrect Educational Objective: Diagnose adrenal insufØciency. Key Point: Increases in cortisol levels above 20 mcg/mL after ACTH stimulation excludes adrenal insufØciency. Explanation: An increase in cortisol levels of more than 20 mcg/dL following ACTH stimulation excludes adrenal insufØciency. The low- and high-dose ACTH stimulation tests have similar rates of sensitivity and speciØcity. Some advocate a morning cortisol level as an initial screening test for adrenal insufØciency in ambulatory patients. A morning cortisol level below 3 mcg/dL is speciØc for adrenal insufØciency, and a morning cortisol level higher than 20 mcg/dL excludes all but the earliest cases of adrenal insufØciency. Once the diagnosis of adrenal insufØciency is conØrmed, an ACTH level should be drawn to localize the defect to the adrenal gland or the hypothalamic-pituitary axis. In primary adrenal insufØciency, ACTH levels are most often above normal and hyperkalemia is common. In secondary adrenal insufØciency, ACTH levels are low or inappropriately normal. References: Bleicken B, Hahner S, Ventz M, Quinkler M. Delayed diagnosis of adrenal insufØciency is common: a cross-sectional study in 216 patients. Am J Med Sci. 2010;339(6):525-531. Nieman, LK. Adrenal cortex. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016:1514-1521 19. Incorrect Question Tools: Report Question  ę ȧ Which of the following is NOT part of an appropriate preoperative regimen for a patient undergoingresection of a an adrenal pheochromocytoma? Ə Discontinue allergy medication. Ǝ Metoclopramide for nausea control. Ǝ Liberalize salt intake (high-sodium diet) at least 10 days prior to surgery. Ǝ Start an alpha-/beta-adrenergic blockade. Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d2/15/2020 Med-Challenger https://app.challengercme.com/prescription/3033894?scored 26/26 Incorrect Educational Objective: Describe the preoperative management of pheochromocytoma. Key Point: Preoperative management of pheochromocytoma involves controlling hypertension and tachycardia as well as volume expansion. In addition, agents known to provide a pheochromocytoma paroxysm (eg, histamine, metoclopramide) should be avoided. Explanation: Agents known to induce a pheochromocytoma paroxysmal crisis include glucagon, histamine, and metoclopramide, and they should be avoided until after a successful surgery. Intraoperative hypertensive crises are a signiØcant complication that can be improved by controlling hypertension, usually with a combined alpha- and betaadrenergic blockade. Alpha-adrenergic blockers are given 10 to 14 days prior to surgery to normalize blood pressure and to expand the contracted blood volume. A beta-adrenergic blockade is usually started 2 to 3 days prior to surgery, and it should never be done prior to the alpha-adrenergic blockade because it can lead to worsening hypertension. Calcium channel blockers and metyrosine, which inhibits catecholamine synthesis, can also be used. Patients with pheochromocytomas are at risk for developing hypotension immediately after removal of their tumors. To reduce this risk, patients should be started on high-sodium diets (no salt restrictions) for at least 10 days prior to surgery. This will help expand their plasma volume and prevent hypotension. In addition, during surgery, normal saline should be provided. References: Young WF Jr. Clinical presentation and diagnosis of pheochromocytoma. (https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-ofpheochromocytoma) Revised September 20, 2016. Accessed July 28. 2017. Yu R. Pheochromocytoma. In: First Consult. 2012. Accessed April 5, 2017. © Challenger Corporation, LLC 2020 Terms & Conditions (https://challengercme.com/support/) Seth Owen ([email protected]) ! Dashboard (/) ± My Assignments (/my-a ƅ Study & Review ø ı CME Credits ø ’ Notes & Bookmarks (/n ƾ My Activity ø ǐ My Assets (/assets) • Quick Quiz (/quickquiz Ǎ News & Updates (/new € Store (/store) ë Help ø _ () (/) Search p € () 0 d [Show More]

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