Hypo or Hyper?
Increase in Na+
Increase in BG
HTN
Moonface/red face
Striae
Decreased immune function
HYPERaldosteronism
Your patient with a history of adrenal insufficiency comes in with muscle weakness, dark skin and mucous membrane pigmentation, and emotional lability. They state they just graduated from law school and are waiting to take the bar. What might they have?
What is Hypoaldosteronism?
Avoid:
-Extreme stress
-Extreme temperatures
They have a shortage or impaired function of a hormone called "aldosterone". Check out the lab section to see what their labs might be.
Your client has just been acutely diagnosed with Addisonian Crisis. What might be your next steps in protocol?
Addisonian Crisis:
you can give D5 or NS (because they will have hyponatremia)
monitor BP and VS and routine lab work
Check BG and have the patient as a fall risk.
Your patient with an autoimmune disorder has lab work as follows:
Na+: 130
K+: 6.0
Glucose: 69
pH: 7.32
HCO3: 20
What might you conclude is going on with this patient? Are these values normal?
Low sodium, high potassium, low pH, and low HCO3 might be indicative of hypoaldosteronism and metabolic acidosis. This could lead to systemic issues such as cardiovascular collapse, but most notably
Addisonian Crisis.
Na+ 135-145
K+ 3.5-5
Glucose: monitor for anything 70 or below
WNL is considered 70-110
pH 7.35-7.45
HCO3 22-26** (Galen values)
Tells the kidneys to absorb sodium into the bloodstream. Releases potassium into the urine to regulate BP.
Aldosterone
Dehydration
low BP
Hyperkalemia
N/V
Generalized weakness
hypoaldosteronism-Addison's disease
Well, I had a recent respiratory infection and I have a history of COPD. I feel better I have lots of energy, but I feel like I might have too much energy. I have trouble sleeping, I'm always hungry, my skin is thin, especially on my face which is weird, and actually, my face looks all puffy like a chipmunk. I don't know. I'm just kind of uncomfortable. Do you know what might be going on?
The patient had a recent respiratory infection and a history of COPD. What it sounds like is hyperaldosteronism or Cushing's related to an excess of steroids.
This patient is also going to have hypercarbia associated with their COPD. They most likely are routinely on steroids for this disease and the additional steroids have sent them into hyperaldosteronism.
In order to be sure the patient will be given an order for a 24 hr urine and what is called an Oral Dexamethasone test at night. 2/3 abnormal tests = hyperaldosternism
Your treatment plan is as follows:
-Alpha Adrenergic Blockers
-Catecholamine Synthesis Inhibitors
-US for mass
-24 hours urine
-Clonidine Suppression test
What might we be treating for?
Phenochromocytoma
Possible meds:
-Alpha-adrenergic blockers, beta-blockers, Calcium channel blockers, catecholamine synthesis inhibitors
monitor:
-tyramine
BP-HTN= very bad
Labs orders as follows:
- Serum ADH (low)
- Renal panel (Na up, K low, urine osmolality low)
- Glucose
- Urine and serum electrolytes
- Water deprivation test
What might this diagnosis be?
Diabetes insipidus
Helps control the body's use of fats, proteins, and carbohydrates.
Suppressed inflammation
Regulates blood pressure
increases blood sugar
can decrease bone formation
What is cortisol?
Excessive cortisol production
Women aged 20-40 are 5x more likely than men to develop
HYPERcortisolism/Cushings
Well, I had surgery to remove a pituitary tumor two weeks ago. I've been using the prescribed mouth wash and I haven't been brushing my teeth like I was told, but I have this light pink fluid still coming out of my mouth. I feel like I have a lost of drainage in the back of my throat. Should I be worried?
Medical Management (Cushing Disease)
If caused by Pituitary Tumors → Surgical Removal of Tumor via → TRANSSPHENOIDAL HYPOPHYSECTOMY (CSF LEAK)
-If CSF leaks (NOTIFY DR AND PT MUST GET SURGERY) *light pink CSF* - MEDICAL EMERGENCY
How do we know if this patient is losing CSF
- If you look at the nasal packing and you see something pinkish and then you see that drainage has this Halo that is CSF this is a medical emergency → NOTIFY PCP because they have a CSF leak and they need to go back to surgery immediately
- Another SIGN of CSF leak is if the conscious patient says
“You know I feel like there's something salty, and I and I feel a whole bunch of drainage at the back of my throat”
That is CSF drainage → NOTIFY PCP
Hyperaldosterism:
Monitor labs especially K+ (tele/cardiac monitor) K+ will be low so they may be given Spironolactone.
monitor Na+ (might be high), Ca+ (might be low), may have hypervolemia. monitor VS and BP
Reduce the patient's anxiety and stress by reducing stimulation and helping them be comfortable. Have seizure precautions in place.
This is a test.
Withhold fluids for 8-12 hours.
Check patients weight frequently.
At the beginning and end of this test, you perform plasma and urine osmolarity studies
an inability to increase the specific gravity and osmolality=diabetes insipidus.
What test might we be performing?
Fluid deprivation test
FLUID DEPRIVATION TEST
○ Withhold fluids for 8 to 12 hours (or until 3% to 5% of the body weight is lost).
○ Weigh patients frequently during the test. ○ Perform Plasma & Urine Osmolality studies (at the beginning & end of testing).
○ INABILITY to INCREASE the Specific Gravity & Osmolality (of the urine) = characteristic of Diabetes Insipidus!
■ The patient continues to excrete large volumes of urine with low specific gravity.
■ The patient experiences → Weight Loss, Increasing Serum Osmolality, & Elevated Serum Sodium levels.
○ Monitor symptoms frequently during the test!
○ STOP FLUID DEPRIVATION TEST IF:
■ Tachycardia, Excessive Weight Loss, or Hypotension develops.
Responsible for the secretion of aldosterone.
ACTH-controls the secretion of Adrenal Cortex Androgens.
Adrenal cortex
Low cortisol
low BP
Cyanosis
Fever
Tachypnea
Rapid weak pulse
Confusion
Headache
Can cause vasodilation and if left untreated can lead to circulatory collapse, shock, or death
Addisonian Crisis or HYPOaldosteronism
Tx: immediate IV
-fluid
-glucose
-electrolytes
may give:
hydrocortisone/dexamethasone NS
vasopressors
I've been depressed for awhile which is really unlike me. I've been struggling a lot and I thought it was just because it's winter. I don't know. I just don't look or feel like myself. I feel swollen everywhere and like my periods used to be normal, but now I never know when I'm going to have them and my hormones seem all over the place. It just sucks. My body is weird. My face keeps breaking out and I have these weird stretch marks-I guess from all the swelling and I think what's really freaking me out is that my sister says I look like Quasimodo.
What is happening to me?
Well, let's check your VS and labs and go from there. It sounds like you might be having some hyperaldosteronism based on your s/s.
Let's discuss CM of hyperaldosteronism and what we might see.
Secondary to head trauma, brain tumor, or surgical ablation or irradiation of the pituitary gland. I have ______ ______.
What might I be given to help?
Diabetes insipidus
anti-diuretic hormone/vasopressin
Concentrated urine
hyponatremia
increases in body weight
fluid retention and edema
we'll need to check CBC, renal panel, urine osmolality.
What might I be?
SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)
- pee is thick and concentrated and PT’s are poofy
-dilutional hyponatremia
-If Na is super low, you will feel very tired, cramps, weak <120 you’ll start seizing, cerebral edema (brain damage), increase of body weight (osmosis - lack of sodium)
● Patients will:
○ NOT be able to Excrete a Dilute Urine.
○ Hold on to Fluids (fluid retention)
Diagnosis of SIADH
- Elimination of underlying cause rule out cancer and tumors.
- CT, MRI
- AM Cortisol
- TSH
- Serum ADH
- Renal panel
- Sodium - LOW
- Urine osmolality
- CBC
Assists ovaries produce estrogen and testes produce testosterone
Androgen
Hypertension
Headache
Hyperhidrosis
Hypermetabolism
Hyperglycemia
Woah, that's a lot of hypers. I might be a diagnosis of...
Diagnosis of Pheochromocytoma ***
- 24-hour urine, specific lab tests (catecholamines and metanephrine)
- Diagnosed by clinical manifestations:
o Hypertension
o Headache
o Hyperhidrosis (excessive sweating)
- Hypermetabolism
- Hyperglycemia
- Plasma and urine catecholamine levels
- Clonidine suppression test – they give you a med and it helps you diagnosis this
- CT, MRI, Ultrasound of abdomen/pelvis
Excessive loss of water through peeing. I keep drinking and I'm so thirsty, but I just keep peeing. I don't know what's going on.
Pathophysiology of Diabetes Insipidus
- Failure of the renal tubules to respond to ADH; this nephrogenic form may be related to hypokalemia, hypercalcemia, and a variety of medications
- A disorder of insufficient ADH activity characterized by excessive loss of water in the urine
- ADH acts directly on the renal collecting ducts and distal tubules, increasing membrane permeability and reabsorption of water
- Most common disorder of the posterior lobe of the pituitary gland and is characterized by a deficiency of ADH
o Anti-diuretic hormone/vasopressin
- Super dehydrated – excessive thirst – polydipsia
Bed rest with HOB elevated
Alpha-adrenergic blocker (dibenzyline), (minipress), (hytrin), or (cardura) – first choice
● Teach pt to change positions slowly -> OT HTN
● Monitor salt intake & BP
● Report blurred or hazy vision
Treatment for????
Pheochromocytoma
Treatment of Pheochromocytoma
- Medical
o Bed rest with head of bed elevated, control of blood pressure before and during surgery
- Surgical
o Adrenalectomy
- Medications
o Alpha-adrenergic blocker (dibenzyline), (minipress), (hytrin), or (cardura) – first choice
● Teach pt to change positions slowly -> OT HTN
● Monitor salt intake & BP
● Report blurred or hazy vision
o Beta-adrenergic blocker (propranolol)
o Ca-channel blockers (procardia or cardene), metyrosine, catecholamine synthesis inhibitors (demser)
Pheochromocytoma can lead to an HTN crisis. We might want to monitor what element that can be found in preserved or pickled foods?
Tyramine
Controls water and conserve sodium in the body.
Aldosterone