1. Differential for acute recurrent hypoglycemia with hypotension requiring constant blouses of fluid and D50
- exogenous insulin/hypoglycemic drugs
- fulminant liver failure
- sepsis
- adrenal insufficiency (loss of all leads to hypotension , would expect higher K, lower Na. Loss of cortisol leads to hypoglycemia) diagnose with ACTH stim test
2. Types of adrenal insufficiency-
Primary (aka Addison's) - failure of adrenals to respond to ACTH -
Secondary - failure of pituitary to produce ACTH, adrenals are fine
Tertiary- failure of hypothalamus to produce CRH
3. ACTH stim test 
- Rules out primary AI
- Doesn't rule out secondary or tertiary AI, obviously, because in those cases the adrenals are able to respond fine to ACTH
- Give 100 mcg ACTH, measure cortisol levels at 0, 30, 60 mins, cortisol should be >21
4. Addison's leads to everything crashing and burning (BP, electrolytes), while secondary adrenal insufficiency can present with only hypotension with no electrolyte abnormalities
Causes:
- autoimmune
- infectious (TB, disseminated fungal, syphillis)- suspect in international people
- hemorrhage (Waterhouse-Friderichsen)
- mets (lung, breast, melanoma, stomach/colon rarer)
- drugs (Azoles, etomidate inhibit cortisol biosynthesis; other drugs that are cyp-inducers like phenytoin, barbituates, rifampin will accelerate hepatic degradation of cortisol) These drugs, esp latter category, rarely cause AI in healthy people but may tip someone with poor adrenal reserve over the edge.
5. Treatment
- Replace glucocorticoids and mineralcorticoids
- Hydrocortisone (20 mg in the AM, 10 mg at 3 PM to mimic diurnal variation). Varies per person-- some people will get cushings from these doses and will need reduced dose.
- Florinef (0.1 mg qD) to replace mineralcorticoids
- Acute - High dose hydrocortisone 50-100 mg IV push q8 until symptoms resolve. Will cover both gluco and mineralcorticoids
6. Autoimmune polyglanduar sx type 2
- includes Schmitts and carpenters syndrome
- all have Addison's, most present with thyroid, some have type 1 DM too. Some will present with minor autoimmune conditions too (alopecia, seroneg arthritis, etc)
7. DDx for obesity, gynecomastia, galactorrhea
- how to differentiate breast tissue from adipose deposits in anterior chest - adipose is compressible, breast tissue is not
- prolactin causes galactorrhea, obesity (peripheral estrogen conversion) leads to gynecomastia
- drugs (spirinolactone, ketoconazole) - most common
- idiopathic
- cirrhosis
Rarer-
- hypogonadism
- testicular cancer that makes b-hcg
- hyperthyroid
- CKD
8. Any prolactin > 200 is a tumor
- Treat with dopamine agonist (carbegoline, dostanex, one tablet twice a week). Should see prolactin decrease in 24 hours, will see tumor shrinking in a week.
- Titrate meds to prolactin <10 for a year, then re-image, if tumor is still present, go on half dose and see if the tumor comes back, if it does you need lifelong tx
- Dopamine agnoists can cause cardiac valve thickening/abnormalities so you need a baseline echo before staring treatment
- Lipids, insulin resistance improve with treatment - some literature about using dopamine agonist to treat diabetes, as prolactin may be implicated in metabolic syndrome
9. FOBT
- Screening test
- False positives can be caused by recent ingestion of red meat (Hb in meat will light up the test), trauma during rectal exam. Thus patient should not be eating red meat before the test
- If someone is going to be admitted for GI bleed, it should be significant-- ie visible on the glove as either red or black. If blood is not grossly visible, the bleed is not serious enough to require admission. Thus don't do an FOBT in the ER
10. Melena
- Is midnight black, tarry/sticky, and has a strange/bad odor different from typical stool
- Not just dark, otherwise normal appearing stool.
- Things that can cause dark-appearing stool: pepto bismol, milk of magnesia, iron supplements