Endocrinology and Mental Health Med-Challenger Chapter Exam
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Course
NURS
Institution
NURS
Stem & Answers
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 t...
stem amp answers a 35 year old man presents with fatigue
and lethargy for the last 3 years he has no medical history he takes a multivitamin but no other medications he smokes 1
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St
em &Answer
I s
A35-y ear-
oldmanpr esentswit
hf ati
gue,l
os
sofli
bido,andlethar
gyfor I
t
Ihelas t3years.Hehasnomedi calhi
st
ory
.Hetakesamul ti
vit
aminbut
noot
I hermedi cati
ons.Hesmok es1packofc i
garetesev er
yweekand
dr
I i
nks1gl ass ofwineeachni
I ght.Hedoesnotusedr ugs.Heisthe
manageratar
I etai
lclot
hings
tore.
Hisreviewofs ympt omsi snotabl
ef ora15-poundwei ghtlos
ss incehis I
l
Iastvisi
t3y earsago.Vi tals
ignsar e:temperature37.4° C,heartrat
e95
beat
I s/minute,bloodpr essure110/ 65mm Hg,r espi
rator
yr at
e14 I
br
I eaths/minute,andoxy gens at
uration99%onr oom air
.Findingsonhis I I
head,ear
I s,ey es,nos e,andt hr
oatexami nati
on,aswel lasexami nati
ons
ofhi
I sneck ,heart,lungs,abdomen,andneur ologi
cstatusareallnor
mal.
IHiss ki
nappear stanned,evenunderhi sclothes.
Youor derl
abor
atorystudi
est hatshowanor malcompl etebl oodcount,
Isodium lev
elof130,pot
I as
si um l
evelof5.1,chlori
delev elof110,
I
Ibicarbonat
elevelof25,bloodur eani
trogenlevelof13,cr eati
ninelev
el
Iof0.8,andglucoselevelof90.Yoususpec tadrenalinsuffici
ency .
Whati
sthenext
tes
ttoor
dert
oconf
ir
mthi
sdi
agnos
is? I
,Increasesi ncor
ti
sol
lev
elsabov
e20mc
g/mLaf
terACTHst
i
mul
ati
onexcl
udesadr
enal
Iinsuffic
ienc
y.
Expl
anat
ion:
Ani ncr easeincor t
isol level
sofmor ethan20mc g/dLfolowingACTHs t
imulat
ionexc ludes
Iadrenal insufficiency.Thel ow-andhi gh-
doseACTHst imulati
ont est
shav esimilar
rat esof
Isensi t
ivi
tyandspec if
icit
y.Someadv ocateamor ningcorti
sollevelasani nit
ial
screeIningtest
If
oradr enalinsuffici
enc yinambul at
orypat ients
.Amor ningcor t
i
sollevelbelow3mc g/dLis
Ispecif
icforadr enali
nsuffici
ency,andamor ni
ngcor ti
sol
le velhi
gh ert
ha n2 0mc g/dLe xcl
ud es
Ialbut t hee a r l
iestca ses ofadrenali
nsuf
fi
c iency
.
Oncet hediagnosisofadr enali
nsuffici
encyisconf
ir
med,anACTHl evelshoul
dbedrawnto
Il
ocali
z ethedefecttotheadr enalgl andort hehypothal
amic-
pitui
t
aryaxis.Inpri
mar
yadrenal
Ii
nsuffic
iency,ACTHl evel saremostof t
enabovenor malandhyperkalemiaiscommon.I
n
Isecondar yadrenali
nsuffici
ency,ACTHl ev
elsareloworinap
pIropri
atel
ynormal.
Ref
erences:
Blei
ckenB,HahnerS,Vent
zM,Quinkl
erM.Del
ayeddiagnosi
sofadrenalinsuffici
encyi
s
Icommon:acros
s-sect
i
onalst
udyi
n216pati
ent
s.AmIJMedSci .2010;
33I9(
6):525- 531.
Nieman,LK.Adrenalc
ort
ex.I
n:Gol
dmanL,Schaf
erAI
.Gol
dman-
Cec
ilMedine.25t
ci hed.
,
I2016:
1514-1521
Quest
ion2
Edi
ted:Oct7,2016
Repor
tQuest
i
on
St
em &Answer
I s
I
nwhi chofthef ol
l
owi
ngpati
entswi
thadr
enali
nsuffic
ienc
yist
her
apy
wi
I t
hfludrocort
isonesnec
essary
?
Charac t
eri
zethet
her
apeut
i
cdi
fer
encebet
weeInpr
imar
yandsecondar
yadr
enal
Ii
nsuffic
iency.
KeyPoi
nt:
Replacementwi
ththemi neral
ocor
ti
coi
dfludrocor
ti
sonesisonl
ynecessar
yfort
hosewi
t
h
Ipr
imaryadr
enali
nsuffici
encysuchasaut oimmuneAd dIi
sondi
sease.
Expl
anat
ion:
Fludrocort
isonet
herapyisreservedf orpati
entswhohavepri
maryadrenalfai
l
ure,because
Ibot
hcor ti
solandaldost
eronesecr eti
onsareafect
edduetodestr
uct
ionoftheentir
eadrenal
Icortex.Ofthecasesdesc r
ibed,the24- year-ol
dwithaut
oimmuneAdd i
sond i
seaseistheonl
y
Ipat
ientwithpri
maryadrenalinsuffic
iency.
Theot herpatient
slistedhavesecondaryadr
enalfai
l
ure.I
nthesecases,thereni
n-
Ia l
dost
erone-angi
otensinsyst
emIconti
nuestoworknormaly,maki
ngreplacementwit
h
If
ludr
ocort
isonesunnIeces
sary.
WhitePC.Adr enocort
ical
insuffic
iency.I
n:Kl
i
egmanRM,etal
,eds
.Nel
sonText
bo
oIkof
IPediat
ri
cs.20thed.,2016:2703- 2714.
Quest
ion3
Edi
ted:Oct7,2016
Repor
tQuest
i
on
St
em &Answer
I s
A45-year-
oldmanpr esent
stoy oubecauseofar educedli
bidoand
i
mpot
I ence.Hes t
atesthathebegannotici
ngi s
sueswi thhisli
bidoabout
1y
I earagobuthei smoreconc er
nednowbecaus ehehasbeennot ic
ing
t
hathi
I schestappear stobedev el
opi
ngabr eas t-li
keappearanc e(mor
e
t
i
Is
sue,dar kerandl ar
gernippl
es)andthetadal af
ilheistaki
ngf or
er
I ecti
l
edy sfunct
i
ondoesnots eemtobehel pi
I ngaswel lasitdidbef
ore.
Hedeni
I esanyot herhealt
hissues.
Onexami nat
ion,hi
svit
alsi
gnsarenor
malandyouconfir
mthepr
esence I
ofgy
I necomas ti
a.Thetes
tesar
esmallandi
nsens
it
ive.Noabdominal
Imas
sesar epalpable.
, Yous endthepatientfordiagnost
ictest
inganddiscoverl
evelsof
es
I t
rogenof178pg/ dL( normalrange,13-54pg/dL)
,lut
eini
zi
nghormone
of0.
I 2,foll
i
cular
-sti
mulati
nghor moneof0. 3,andtest
ost
eroneof67pg/dL
(
Inor
malr ange,250-800pg/ dL)
.
Computedtomogr
aphy(
CT)showsa7.
3-cm,i
rr
egul
armas
s ont
her
ight I
I Descr
ibet
hewor
kupandt
reat
mentf
oral
argeadr
enalmas
s.
I KeyPoi
nt:
Adrenalmasseswi
t
hsuspi
ci
ousi
magi
ngphenot
ypeorsi
zel
argert
han6cmIshoul
dbe
Ir
esected.
Expl
anat
ion:
Thepat i
entdescri
bedhasal arge(>6cm)adr enalmass,whichissuspici
ousf
or
Iadrenocor t
i
calcancer;t
hus,thepati
entshoul
dunder gor
esec t
i
onoft hemass Anyi
. nci
dent
al
Ima ssIoftheadrenal
sgreat
ert han6cmIinsiz
eoranymas sIevidencedonworkupfora
Isuspectedadrenaldisor
derthatisoft
hissi
ze,requi
ressur
gicalresecti
on.
Radi
ol
ogi
cchar
act
eri
st
icssug
gest
i
veofmal
i
gnanc
yincl
ude:
• I
rregularmargins
• Lackofhomogenei ty
• Soft-
ti
ssuecalc i
f
icat
i
onsvisi
bl
eonCT
• Hyperintensi
t
ycompar edwit
hli
veronT2-
wei
ght
edmagnet
icr
esonancei
magi
ng
Adrenalnoduleswi
thl
owCTat enuat
i
onvalues(<10Hounsf
iel
dunit
s)andf
indi
ngsonrapid
Icont
rastwashout(
washoutmor
ethan50%Iaf
ter10mi
nut
es)ar el
ik
elytobebenign.Though
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