Case Presentation 64 y.o. Caucasian man with ‘nodular enlargement of both adrenal glands’ Chief complaint: Mr F. is a 64 year old Caucasian male who came to the clinic to follow up with the nurse practitioner on an incidental finding of enlargement of both adrenal glands, as directed. He had been to the ED of a local hospital 3 weeks before complaining of flank pain, and was diagnosed kidney stones. On a CT scan done during that visit, ‘nodular enlargement of both adrenal glands without discrete mass’ was seen incidentally, and he was advised to follow-up. Mr F is married, and his wife is presentat the visit as well. a full-time barber who has no health insurance, is married and has 2 grown childrenToday, the patient denies appears well and comfortable, as he sits in the exam room. but slightly anxious as he sits in the exam room next to his wife. is feeling well, and he and his wife are into see the nurse practitioner today. He is here to follow up.

Cushings

“moon face”, “buffalo hump”

Question: Which of the following serum lab findings are found in the client with Cushing’s syndrome? Increased cortisol, decreased sodium, and decreased potassium levels Decreased cortisol, decreased potassium, and decreased glucose levels Increased cortisol, increased sodium, and decreased potassium levels Normal BUN, increased sodium, and increased potassium levels C – plus decreased glucose, and normal BUN

What 3 hormones are the adrenal glands responsible for producing? Question: What 3 hormones are the adrenal glands responsible for producing? Corticotropin Releasing Hormone (CRH), ACTH, cortisol Estrogen, progesterone, androgens Aldosterone, cortisol, androgens ACTH, catecholamines, angiotensin C – Aldosterone regulates fluid/electrolyte balance; Cortisol regulates blood glucose levels, Controls reactions to stress and regulates many body processes (such as digestion, immmune system, mood & emotions, sexuality, energy storage & expenditure

Hypothalamus – Pituitary – Adrenal Axis (AKA Gonadotropic Axis) : A Complex set of direct influences & feedback interactions between the hypothalamus, pituitary gland, and adrenal glands. Controls reactions to stress and regulates many body processes (such as digestion, immmune system, mood & emotions, sexuality, energy storage & expenditure)

Hypothalamus –Pituitary-Adrenal Axis The adrenal glands are retroperitoneal and are located on the superior medial aspect of the upper pole of each kidney (figure 4). Gerota's fascia and pararenal fat separate the adrenals from the ribs, the pleural reflection, and the subcostal, sacrospinalis, and latissimus dorsi muscles

The adrenal glands are orange-colored endocrine glands located at the top of each kidney. The right gland is pyramid-shaped (“witch’s hat”) and lies above the upper pole of the right kidney, between the liver and the diaphragm. The left gland is found between the kidney and aorta, near the tail of the pancreas and the splenic artery. They are triangular shaped and measure about ½ inch in height, and 3 inches in length Each gland consists of a medulla (center of the gland) surrounded by a cortex. The medulla and cortex are two functionally distinct units, contained within a single capsule (figure 1). Each has distinct embryologic, anatomic, histologic, and functional characteristics (Roman & Wu, 2012). Adrenocortical diseases are classified on the basis of whether there is hormone deficiency or excess. The medulla is responsible for producing epinephrine & norepinephrine. The adrenal cortex produces other hormones necessary for fluid & electrolyte balance (cortisone & aldosterone) & also makes sex hormones

Cortisol, aldosterone, & androgens epinephrine & norepinephrine The medulla is responsible for producing epinephrine & norepinephrine (GAS). The adrenal cortex secretes 3 types of hormones: glucocorticoids (cortisol), mineralcorticoids (aldosterone), and sex hormones (androgens, estrogen, progestrone); fluid & electrolyte balance (cortisone & aldosterone) & secondary sex characteristics Cortisol, aldosterone, & androgens epinephrine & norepinephrine

The Take Home: The 3 most common types of adrenal gland disorders are: Addison’s Disease Cushing’s Syndrome Pheochromocytoma But be aware of the zebras!!! FYI: Addison’s – lost aldosterone production (hypo-Na, hyper-K) Cushing’s – 24-hour excretion of cortisol in the urine (elevated x 2-3 tests) Pheochromocytoma – elevated levels of catecholamines in 24-hour urine